NPIMap

Organization Active NPI

Mason Park Healthcare, Inc.

Doing business as Lakeside Rehabilitation and Care Center

  • Skilled Nursing Facility
  • Coeur d'Alene, ID
National Provider Identifier
1487453494
Registry record updated May 27, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
MASON PARK HEALTHCARE, INC.
Doing business as
Lakeside Rehabilitation and Care Center
Practice address
210 W Lacrosse Ave
Coeur D Alene, ID 83814-2403
Phone
(208) 664-2185
NPI assigned
Mar 11, 2025
Last updated
May 27, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 27, 2025

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

Authorized official

Name
Soon Burnam
Title
Secretary
Phone
(949) 540-1249

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

210 W Lacrosse Ave
Coeur D Alene, ID 83814-2403

Mailing address

210 W Lacrosse Ave
Coeur D Alene, ID 83814-2403
Phone (208) 664-2185

Other names 1

  • Lakeside Rehabilitation and Care Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250512003104 ID Part A Provider - Skilled Nursing Facility 1254858327 Practice locations: Coeur D Alene, ID

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1487453494. Details of each certification follow.

Skilled nursing facility certification: CCN 135042

Legal name
MASON PARK HEALTHCARE, INC.
Doing business as
LAKESIDE REHABILITATION AND CARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Dec 13, 1967
Last certification
Oct 11, 2024
Beds
100
Ownership / control type
Corporation
Multi-facility organization
Ensign Services
Organization structure
CorporationProprietary
Enrollment address
210 W Lacrosse Ave
Coeur D Alene, ID 83814-2403
Nursing home name
LAKESIDE REHABILITATION AND CARE CENTER
Affiliated entity
THE ENSIGN GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Lakeside Rehabilitation and Care CenterCCN 135042 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Dec 13, 1967
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
10083.3 residents per day on average
Chain
The Ensign Group342 facilities in the chain
Penalties (3 years)
2Fines totaling $220,832

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D2054638Lakeside Rehabilitation and Care Center210 W Lacrosse Ave, Coeur D'Alene, ID 83814Certificate of waiverFeb 25, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Pushapdeep K Brar Individual Operational/Managerial Control Jun 1, 2025
Managing Control - Governing BodyMedical Director Jun 1, 2025
Adp of the SNF May 5, 2025
Isaiah Hawkins Individual Corporate OfficerPresident of Mason Park Healthcare Sep 20, 2024
Pennant Healthcare LLC Organization, San Juan Capistrano, CA LLC 5% Or Greater Direct Ownership Interest Sep 20, 2024 100%
The Ensign Group Inc Organization, San Juan Capistrano, CA Corporation 5% Or Greater Indirect Ownership Interest Sep 20, 2024 100%
Eric Miller Individual Operational/Managerial Control Jun 1, 2025
Managing Control - Governing BodyAdministrator Jun 1, 2025
Adp of the SNF May 1, 2025
Ami Sato Individual Corporate OfficerTreasurer of Mason Park Healthcare Sep 20, 2024
Stephen W Farnsworth Individual Corporate OfficerPresident Milestone Healthcare LLC Sep 20, 2024
Corporate DirectorDirector Mason Park Healthcare Sep 20, 2024
Soon Burnam Individual Corporate OfficerSecretary of Mason Park Healthcare Sep 20, 2024

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 27

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 27

Practitioners & affiliated clinicians

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1741651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748304000000",
    "number": "1487453494",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "210 W LACROSSE AVE",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838142403",
            "telephone_number": "208-664-2185"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "210 W LACROSSE AVE",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838142403",
            "telephone_number": "208-664-2185"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MASON PARK HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-03-11",
        "last_updated": "2025-05-27",
        "certification_date": "2025-05-27",
        "status": "A",
        "authorized_official_last_name": "BURNAM",
        "authorized_official_first_name": "SOON",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "949-540-1249"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeside Rehabilitation and Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Coeur d'Alene, ID

Sources for this page

Verify at the official NPI Registry.