Provider Demographics
NPI:1093378317
Name:LAKESIDE GLOBAL TRANSPORT, INC
Entity Type:Organization
Organization Name:LAKESIDE GLOBAL TRANSPORT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARION
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-627-9184
Mailing Address - Street 1:8255 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2405
Mailing Address - Country:US
Mailing Address - Phone:313-627-9184
Mailing Address - Fax:313-416-9002
Practice Address - Street 1:8255 2ND AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2405
Practice Address - Country:US
Practice Address - Phone:313-627-9184
Practice Address - Fax:313-416-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle