MEDICARE: LAKESIDE CRISIS STABILIZATION

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility		GA

General Provider Information

NPI Number	:	1598848277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE CRISIS STABILIZATION

Provider Business Mailing Address
First Line	:	600 DOT BARN RD
Second Line	:
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-9353
Country	:	US
Telephone Number	:	912-330-8335
Fax Number	:	912-330-8340

Provider Business Practice Location Address
First Line	:	600 DOT BARN RD
Second Line	:
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-9353
Country	:	US
Telephone Number	:	912-330-8335
Fax Number	:	912-330-8340

Authorized Official
Title or Position	:	RHA
Name	:	CHARLES LI
Credential	:
Telephone Number	:	912-356-2011

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	08/22/2020

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Directions to “LAKESIDE CRISIS STABILIZATION ” Practice Location

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