Provider Demographics
NPI:1609202589
Name:LAKESHORE CARE CORP
Entity Type:Organization
Organization Name:LAKESHORE CARE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-813-5471
Mailing Address - Street 1:304 MADISON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4618
Mailing Address - Country:US
Mailing Address - Phone:616-459-9331
Mailing Address - Fax:616-459-9331
Practice Address - Street 1:8840 CEDAR CREEK DR
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:MI
Practice Address - Zip Code:49425-8599
Practice Address - Country:US
Practice Address - Phone:231-821-0281
Practice Address - Fax:231-821-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM610080832310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5983515Medicaid