Basic Information
| Provider Information | |||||||||
| NPI: | 1780068379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE ALLERGY ENT LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 SUMMER LEE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727715443 | ||||||||
| FaxNumber: | 9727715444 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 SUMMER LEE DR. | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727715443 | ||||||||
| FaxNumber: | 9727715444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 08/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9727715443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.