Organization
LAKESIDE MEDICAL WELLNESS CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STACY W KIRKUM (ADMINISTRATOR)
(337) 625-5050
Entity
Organization
Contact information
Practice address
1908 MAPLEWOOD DR, SUITE B, SULPHUR, LA 70663-6000
(337) 625-5050
(337) 625-6726
Mailing address
1908 MAPLEWOOD DR, SUITE B, SULPHUR, LA 70663-6000
(337) 625-5050
(337) 625-6726
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
MD14484R
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1476269
—
LA
Enumeration date
04/27/2011
Last updated
04/27/2011
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