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General NPI Number Information
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NPI Number | 1801194352
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Entity Type | Organization
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Legal Business Name | LAKESIDE HEART AND VASCULAR CENTER PLLC
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Dates
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Enumeration Date | 03/08/2011
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Last Update Date | 07/20/2011
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Provider Practice Location Address
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Address Line | 1741 MESQUITE AVE SUITE A100
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5695
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Country | US
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Telephone | 928-453-2727
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Fax | 928-453-2828
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Provider Business Mailing Address
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Address Line | PO BOX 3539
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86405-3539
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Country | US
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Telephone | 928-453-2727
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Fax | 928-453-2828
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | FADI ATASSI
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Credential | M.D.
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Telephone | 928-453-2727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 44211
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 207RI0011X
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Taxonomy Name | Interventional Cardiology Physician
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License Number | 44211
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License Number State | AZ
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