Basic Information
| Provider Information | |||||||||
| NPI: | 1790980191 | ||||||||
| EntityType: | 2 | ||||||||
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| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3305 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146451808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 07/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | BANIA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4147669094 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.