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General NPI Number Information
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NPI Number | 1740572395
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Entity Type | Organization
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Legal Business Name | LAKE SIDE MEDICAL CENTER PROFESSIONAL. INC.
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Dates
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Enumeration Date | 05/13/2011
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Last Update Date | 08/09/2024
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Provider Practice Location Address
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Address Line | 4300 CRENSHAW BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90008-4902
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Country | US
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Telephone | 323-298-1668
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Fax |
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Provider Business Mailing Address
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Address Line | 12115 MAGNOLIA BLVD STE 14
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City | N HOLLYWOOD
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State | CA
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Zip | 91607-2609
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Country | US
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Telephone | 818-985-1221
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Fax | 818-985-1222
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRIAN KEITH GAMBLE
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Credential | M.D.
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Telephone | 818-985-1221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 293D00000X
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Taxonomy Name | Physiological Laboratory
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A76121
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License Number State | CA
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