MEDICARE: LAKESIDE HOME MEDICAL EQUIPMENT INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BX2000X	Oxygen Equipment & Supplies (DME)		KY

General Provider Information

NPI Number	:	1477862241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE HOME MEDICAL EQUIPMENT INC

Provider Business Mailing Address
First Line	:	PO BOX 587
Second Line	:
City	:	RUSSELL SPRINGS
State	:	KY
Zip	:	42642-0587
Country	:	US
Telephone Number	:	270-866-2271
Fax Number	:

Provider Business Practice Location Address
First Line	:	2418 S HIGHWAY 76
Second Line	:
City	:	RUSSELL SPRINGS
State	:	KY
Zip	:	42642-8845
Country	:	US
Telephone Number	:	270-866-2271
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. SHELLA ANN HARRIS
Credential	:
Telephone Number	:	270-866-2271

Provider Enumeration Date	:	09/28/2010
Last Update Date	:	09/28/2010

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