Organization
THE LAKESIDE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JAYNE CULBERSON (CFO)
(541) 937-2134
Entity
Organization
Contact information
Practice address
38843 DEXTER RD, DEXTER, OR 97431-9775
(541) 937-2134
(541) 937-1370
Mailing address
PO BOX 110, 38843 DEXTER ROAD, DEXTER, OR 97431-0110
(541) 937-2134
(541) 937-1370
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
084054259N1
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
122416
—
OR
Enumeration date
06/21/2006
Last updated
12/17/2009
Update your record
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