NPIMap

Organization Active NPI

Lakeside Clinic, LLC

  • Methadone Clinic
  • Clearwater, FL
National Provider Identifier
1992162879
Registry record updated Jul 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
Legal business name
LAKESIDE CLINIC, LLC
Doing business as
MedMark Treatment Centers Clearwater
Practice address
13700 58TH St N
Building 2, Suite 201
Clearwater, FL 33760-3757
Phone
(727) 223-3545
NPI assigned
Jan 22, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 29, 2024

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

Authorized official

Name
Bruce Jarvie
Title
VP, Treasurer
Phone
(214) 379-3300

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X
Methadone Clinic 261QM2800X Primary
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X

Addresses

Primary practice location

13700 58TH St N
Building 2, Suite 201
Clearwater, FL 33760-3757

Mailing address

1720 Lakepointe Dr Ste 117
Lewisville, TX 75057-6425
Phone (469) 470-4779

Other names 1

  • MedMark Treatment Centers Clearwater Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL
Opioid treatment program
Medicare-enrolled since Mar 28, 2023

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230721002652 FL Part B Supplier - Opioid Treatment Program (Otp) 5698135655 Practice locations: Clearwater, FL

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
10D2254086Lakeside Clinic LLC Dba13700 58TH Street N, Clearwater, FL 33760Certificate of waiverFeb 28, 2028

National Provider Directory

National Provider Directory

Locations

13700 58th St N
Ste 209
Clearwater, FL 33760
Phone (727) 223-3545

13700 58th St N
Ste 201
Clearwater, FL 33760
Phone (727) 223-3545

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1453420800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722211200000",
    "number": "1992162879",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1720 LAKEPOINTE DR STE 117",
            "city": "LEWISVILLE",
            "state": "TX",
            "postal_code": "750576425",
            "telephone_number": "469-470-4779"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13700 58TH ST N",
            "address_2": "BUILDING 2, SUITE 201",
            "city": "CLEARWATER",
            "state": "FL",
            "postal_code": "337603757",
            "telephone_number": "727-223-3545"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESIDE CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-22",
        "last_updated": "2024-07-29",
        "certification_date": "2024-07-29",
        "status": "A",
        "authorized_official_last_name": "JARVIE",
        "authorized_official_first_name": "BRUCE",
        "authorized_official_title_or_position": "VP, TREASURER",
        "authorized_official_telephone_number": "214-379-3300"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MedMark Treatment Centers Clearwater",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clearwater, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.