Provider Demographics
NPI:1568642791
Name:LAKESHORE INTEGRATIVE HEALTHCARE, LTD
Entity Type:Organization
Organization Name:LAKESHORE INTEGRATIVE HEALTHCARE, LTD
Other - Org Name:DANIEL E VARANAUSKI, DN PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:VARANAUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DN
Authorized Official - Phone:773-972-6566
Mailing Address - Street 1:2731 N SEMINARY AVE
Mailing Address - Street 2:STE #1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1322
Mailing Address - Country:US
Mailing Address - Phone:773-972-6566
Mailing Address - Fax:
Practice Address - Street 1:2202 N LINCOLN AVE
Practice Address - Street 2:STE #1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-7170
Practice Address - Country:US
Practice Address - Phone:312-698-9855
Practice Address - Fax:312-698-9857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL181-000304133N00000X, 172P00000X
IL070010058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No172P00000XOther Service ProvidersNaprapathGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633587OtherBLUE CROSS BLUE SHIELD