Provider Demographics
NPI:1134130172
Name:LAKE DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:LAKE DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-674-8199
Mailing Address - Street 1:3550 PONTIAC LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2337
Mailing Address - Country:US
Mailing Address - Phone:248-674-8199
Mailing Address - Fax:248-674-8205
Practice Address - Street 1:3550 PONTIAC LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2337
Practice Address - Country:US
Practice Address - Phone:248-674-8199
Practice Address - Fax:248-674-8205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4168987-10Medicaid
MI1376540286OtherNPI KACHADURIAN
MI3175190-10Medicaid
MI1437181146OtherNPI MELLEN
MI1891751509OtherNPI KOVAN
MI4661544-11Medicaid
MI4876314-11Medicaid
MI1205824505OtherNPI RUBIN
MI3225247-10Medicaid
MICA2712OtherRAILROAD MEDICARE
MI1346212800OtherNPI BORIN
MI1356349062OtherNPI SILVERMAN
MI1013935071OtherNPI OSTERBERGER
MI1588661391OtherNPI ELKISS
MI700F313270OtherBCBS GROUP PROVIDER
MI4876216-11Medicaid
MI1205824505OtherNPI RUBIN
MI1437181146OtherNPI MELLEN
MICA2712OtherRAILROAD MEDICARE