Provider Demographics
NPI:1568804169
Name:LAKESHORE SENIOR CARE LLC
Entity Type:Organization
Organization Name:LAKESHORE SENIOR CARE LLC
Other - Org Name:LAKESHORE SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOLTHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-994-9900
Mailing Address - Street 1:320 N 120TH AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2696
Mailing Address - Country:US
Mailing Address - Phone:616-994-9900
Mailing Address - Fax:
Practice Address - Street 1:320 N 120TH AVE
Practice Address - Street 2:STE 230
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2696
Practice Address - Country:US
Practice Address - Phone:616-994-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESHORE LEGACY GROUP FAMILY LIMITED PARTNERSHIP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health