Provider Demographics
NPI:1902876337
Name:SUTTER LAKESIDE HOME MEDICAL SERVICES
Entity Type:Organization
Organization Name:SUTTER LAKESIDE HOME MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR /ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:LYKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:707-263-7400
Mailing Address - Street 1:843 PARALLEL DR
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5707
Mailing Address - Country:US
Mailing Address - Phone:707-263-7400
Mailing Address - Fax:707-263-1964
Practice Address - Street 1:843 PARALLEL DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5707
Practice Address - Country:US
Practice Address - Phone:707-263-7400
Practice Address - Fax:707-263-1964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000118251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA07620GMedicaid
CA07620GMedicaid