Provider Demographics
NPI:1598841298
Name:LAKESHORE RESPIRATORY THERAPY CARE SERVICES, INC
Entity Type:Organization
Organization Name:LAKESHORE RESPIRATORY THERAPY CARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAILE
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:820-683-2068
Mailing Address - Street 1:3203 LINCOLN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-1821
Mailing Address - Country:US
Mailing Address - Phone:820-683-2068
Mailing Address - Fax:920-683-9238
Practice Address - Street 1:3203 LINCOLN AVE STE 2
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-1821
Practice Address - Country:US
Practice Address - Phone:820-683-2068
Practice Address - Fax:920-683-9238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9207-045332BX2000X
WI9207-45332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9207-045OtherSTATE DISTRIBUTOR LICENSE
WI41630200Medicaid
WI0437410001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER