Provider Demographics
NPI:1083041297
Name:LAKESHORE REGIONAL ENTITY
Entity Type:Organization
Organization Name:LAKESHORE REGIONAL ENTITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LABAN
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:231-769-2046
Mailing Address - Street 1:5000 HAKES DR.
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441
Mailing Address - Country:US
Mailing Address - Phone:231-769-2046
Mailing Address - Fax:
Practice Address - Street 1:920 DIANA ST
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1987
Practice Address - Country:US
Practice Address - Phone:231-845-6294
Practice Address - Fax:231-845-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health