Organization
LAKESIDE CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CAROLYN H MASON (ADMINISTRATOR)
(256) 582-5131
Entity
Organization
Contact information
Practice address
2337 HOMER CLAYTON DRIVE, GUNTERSVILLE, AL 35976
(256) 582-5131
(256) 582-1100
Mailing address
2337 HOMER CLAYTON DRIVE, GUNTERSVILLE, AL 35976
(256) 582-5131
(256) 582-1100
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
051502549
NIXON PROVIDER NUMBER
—
01
—
051509352
REED-JOHNSON PROVIDER NUM
—
01
—
051518706
FOLEY PROVIDER NUMBER
—
01
—
051550004
LARSON PROVIDER NUMBER
—
01
—
051550006
BOGGESS PROVIDER NUMBER
—
01
—
10014
LARSON AL LIC NUMBER
—
01
—
22839
NIXON AL LIC NUMBER
—
01
—
23185
REED-JOHNSON AL LIC NUMB
—
01
—
25574
FOLEY AL LIC NUMBER
—
01
—
9801
BOGGESS AL LIC NUMBER
—
Enumeration date
09/07/2006
Last updated
04/24/2024
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