| Organization Name: | LAKE SIDE MEDICAL CENTER PROFESSIONAL. INC. |
| NPI Number: | 1740572395 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BRIAN KEITH GAMBLE (PRESIDENT) |
| Mailing Address: | 10701 Riverside Dr Suite 16 Toluca Lake |
| State: | CA US |
| Postal Code: | 916022384 |
| Phone Number: | 8189851221 |
| Fax Number: | 8189851222 |
| NPI Enumeration Date: | 05/13/2011 |
| NPI Last Update Date: | 05/13/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 293D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Laboratories |
| Taxonomy Classification: | Physiological Laboratory |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A laboratory that operates independently of a hospital and physician |