MEDICARE: LAKESIDE CSU

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	323P00000X	Psychiatric Residential Treatment Facility

General Provider Information

NPI Number	:	1518324128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE CSU

Provider Business Mailing Address
First Line	:	600 DOT BARN RD
Second Line	:
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-9353
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 DOT BARN RD
Second Line	:
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-9353
Country	:	US
Telephone Number	:	912-449-7109
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MICHELLE SIMPSON
Credential	:
Telephone Number	:	912-449-7109

Provider Enumeration Date	:	01/27/2016
Last Update Date	:	01/27/2016

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Directions to “LAKESIDE CSU ” Practice Location

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