Provider Demographics
NPI:1417532110
Name:LAKESHORE MANOR MEMORY CARE LLC
Entity Type:Organization
Organization Name:LAKESHORE MANOR MEMORY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:ANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:VISTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-819-2190
Mailing Address - Street 1:8170 MCCORMICK BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2914
Mailing Address - Country:US
Mailing Address - Phone:773-819-2190
Mailing Address - Fax:
Practice Address - Street 1:711 BAY SHORE DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-5218
Practice Address - Country:US
Practice Address - Phone:920-393-3871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-14
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility