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General NPI Number Information
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NPI Number | 1669317129
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Entity Type | Organization
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Legal Business Name | LAKE SIDE LIVING
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Dates
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Enumeration Date | 04/21/2026
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Last Update Date | 04/21/2026
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Provider Practice Location Address
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Address Line | 1830 40TH AVE S APT 213
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City | MOORHEAD
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State | MN
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Zip | 56560-7924
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Country | US
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Telephone | 701-818-5636
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Fax |
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Provider Business Mailing Address
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Address Line | 1830 40TH AVE S APT 213
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City | MOORHEAD
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State | MN
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Zip | 56560-7924
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Country | US
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Telephone | 701-818-5636
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Fax |
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Authorized Official
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Title or Position | RN
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Name | ABDIRAHIM ISMAIL
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Credential | ISMAIL
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Telephone | 218-880-1006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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