Provider Demographics
NPI:1417495169
Name:LAKESHORE VEINS S. C.
Entity Type:Organization
Organization Name:LAKESHORE VEINS S. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:BARTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-241-3999
Mailing Address - Street 1:1361 W TOWNE SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5047
Mailing Address - Country:US
Mailing Address - Phone:262-241-3999
Mailing Address - Fax:
Practice Address - Street 1:1361 W TOWNE SQUARE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5047
Practice Address - Country:US
Practice Address - Phone:262-241-3999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3261440Medicaid