Lakeside Medical Wellness Clinic

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

License

MD14484R Issued in LA

Legal business name

LAKESIDE MEDICAL WELLNESS CLINIC

Practice address

1908 Maplewood Dr
Suite B
Sulphur, LA 70663-6000

Phone

(337) 625-5050

Fax

(337) 625-6726

NPI assigned

Apr 27, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Stacy W Kirkum

Title

Administrator

Phone

(337) 625-5050

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1303862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1303862400000",
    "number": "1407147234",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1908 MAPLEWOOD DR",
            "address_2": "SUITE B",
            "city": "SULPHUR",
            "state": "LA",
            "postal_code": "706636000",
            "telephone_number": "337-625-5050",
            "fax_number": "337-625-6726"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1908 MAPLEWOOD DR",
            "address_2": "SUITE B",
            "city": "SULPHUR",
            "state": "LA",
            "postal_code": "706636000",
            "telephone_number": "337-625-5050",
            "fax_number": "337-625-6726"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE MEDICAL WELLNESS CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-27",
        "last_updated": "2011-04-27",
        "status": "A",
        "authorized_official_last_name": "KIRKUM",
        "authorized_official_first_name": "STACY",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "337-625-5050"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "LA",
            "license": "MD14484R",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1476269",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Koni B. Bridges, LCSW LLC
• Caitlyn Marie Kudrecki, PLPC
• Christine Kudrecki, LCSW
• Lake Area Dentistry-Carlyss
• Lakeside Medical Wellness Clinic
• Paul Gregory Lancon, DC
• Terry Alan Lane, LCSW
• Lannan Family Practice, LLC
• Maureen Rose Lannan, M.D.
• Colin S Laughlin, DPT

• Clinic/Center in Sulphur, LA
• Providers in Sulphur, LA by specialty
• Clinic/Center in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 27, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.