Lakeside Edx LLC

Primary specialty

Radiology Clinic/CenterTaxonomy code 261QR0200X

Legal business name

LAKESIDE EDX LLC

Practice address

495 Grand Blvd Ste 206
Miramar Beach, FL 32550-1897

Phone

(800) 416-1767

NPI assigned

May 11, 2021

Organization subpart

No

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

Authorized official

Name

Mr. Thomas Winger

Title

Member

Phone

(800) 416-1767

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1620691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1620691200000",
    "number": "1730763244",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "495 GRAND BLVD STE 206",
            "city": "MIRAMAR BEACH",
            "state": "FL",
            "postal_code": "325501897",
            "telephone_number": "800-416-1767"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "495 GRAND BLVD STE 206",
            "city": "MIRAMAR BEACH",
            "state": "FL",
            "postal_code": "325501897",
            "telephone_number": "800-416-1767"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE EDX LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-11",
        "last_updated": "2021-05-11",
        "certification_date": "2021-05-11",
        "status": "A",
        "authorized_official_last_name": "WINGER",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "800-416-1767",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Cynthia L Klein, RPH
• Rebecca Sue Klein, BCBA
• Christian Krueger, APRN
• L Scott Horne DMD PL
• Judith Ann La Marche, PH.D.
• Eric H Lamb, LCSW
• Martin J Landa, M.D.
• Corinne Larocco, LMT
• Elizabeth Hillary Lasch, RN
• Jesus Ricardo Leon Noa, MD

• Radiology Clinic/Center in Miramar Beach, FL
• Providers in Miramar Beach, FL by specialty
• Radiology Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 11, 2021; 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.