Provider Demographics
NPI:1104365279
Name:LAKESIDE ALLERGY ASTHMA AND IMMUNOLOGY LLC
Entity Type:Organization
Organization Name:LAKESIDE ALLERGY ASTHMA AND IMMUNOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LI
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-535-0946
Mailing Address - Street 1:PO BOX 2227
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-0039
Mailing Address - Country:US
Mailing Address - Phone:678-837-5224
Mailing Address - Fax:404-860-1298
Practice Address - Street 1:3500 DULUTH PARK LN STE 820
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3243
Practice Address - Country:US
Practice Address - Phone:678-226-9866
Practice Address - Fax:678-373-3983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75964261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty