MEDICARE: LAKE SIDE MEDICAL CENTER PROFESSIONAL. 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	293D00000X	Physiological Laboratory
2	174400000X	Specialist	A76121	CA

General Provider Information

NPI Number	:	1740572395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SIDE MEDICAL CENTER PROFESSIONAL. INC.

Provider Business Mailing Address
First Line	:	12115 MAGNOLIA BLVD STE 14
Second Line	:
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91607-2609
Country	:	US
Telephone Number	:	818-985-1221
Fax Number	:	818-985-1222

Provider Business Practice Location Address
First Line	:	4300 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4902
Country	:	US
Telephone Number	:	323-298-1668
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN KEITH GAMBLE
Credential	:	M.D.
Telephone Number	:	818-985-1221

Provider Enumeration Date	:	05/13/2011
Last Update Date	:	08/09/2024

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