Organization
LAKESIDE LIFE RECOVERY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DON PERRY JOHNSON SR. (EXECUTIVE DIRECTOR)
(972) 754-6257
Entity
Organization
Contact information
Practice address
341 COUNTY ROAD 4874, NEWARK, TX 76071-3715
(817) 831-4673
Mailing address
2909 RACE ST, FORT WORTH, TX 76111-4134
(817) 831-4673
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Enumeration date
01/14/2011
Last updated
01/14/2011
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