Organization
LAKESIDE TLF, LLC
Active
Other names
Lakeside Neurologic
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MANEESH BANSAL MD (COO)
(800) 697-5390
Entity
Organization
Contact information
Practice address
1962 VANDOLAH RD, WAUCHULA, FL 33873-8726
(800) 697-5390
Mailing address
10866 WASHINGTON BLVD STE 42, CULVER CITY, CA 90232-3610
(213) 986-8416
Taxonomy
Speciality
Code
Description
License number
State
283X00000X
Rehabilitation Hospital
Primary
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
—
—
320700000X
Physical Disabilities Residential Treatment Facility
—
—
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
—
—
Other
Enumeration date
11/17/2020
Last updated
11/17/2020
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