Provider Demographics
NPI:1902981061
Name:LAKESIDE LUTHERAN HOME
Entity Type:Organization
Organization Name:LAKESIDE LUTHERAN HOME
Other - Org Name:LAKESIDE LUTHERAN HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PORATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-852-4060
Mailing Address - Street 1:301 N LAWLER ST
Mailing Address - Street 2:
Mailing Address - City:EMMETSBURG
Mailing Address - State:IA
Mailing Address - Zip Code:50536-1073
Mailing Address - Country:US
Mailing Address - Phone:712-852-4060
Mailing Address - Fax:712-852-9914
Practice Address - Street 1:301 N LAWLER ST
Practice Address - Street 2:
Practice Address - City:EMMETSBURG
Practice Address - State:IA
Practice Address - Zip Code:50536-1073
Practice Address - Country:US
Practice Address - Phone:712-852-4060
Practice Address - Fax:712-852-9914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA740436311500000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0802181Medicaid
IA165492Medicare Oscar/Certification