Basic Information
Provider Information
NPI: 1497983837
EntityType: 2
ReplacementNPI:  
OrganizationName: LAKESHORE MEDICAL CLINIC LLC
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Mailing Information
Address1: 3301 W FOREST HOME AVE
Address2:  
City: MILWAUKEE
State: WI
PostalCode: 532152843
CountryCode: US
TelephoneNumber: 4146476326
FaxNumber:  
Practice Location
Address1: 4202 W OAKWOOD PARK CT
Address2:  
City: FRANKLIN
State: WI
PostalCode: 531328131
CountryCode: US
TelephoneNumber: 4144235250
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/24/2009
LastUpdateDate: 07/20/2017
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: BANIA
AuthorizedOfficialFirstName: MICHAEL
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AuthorizedOfficialTitleorPosition: SENIOR DIRECTOR
AuthorizedOfficialTelephone: 4147669094
IsSoleProprietor:  
IsOrganizationSubpart: N
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332B00000X  Y SuppliersDurable Medical Equipment & Medical Supplies 

No ID Information.


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