Provider Demographics
NPI:1619560026
Name:LAKESHORE CONCIERGE MEDICINE PLLC
Entity Type:Organization
Organization Name:LAKESHORE CONCIERGE MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:W
Authorized Official - Last Name:REXFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-638-1414
Mailing Address - Street 1:1361 FOREST PARK RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4638
Mailing Address - Country:US
Mailing Address - Phone:231-638-1414
Mailing Address - Fax:
Practice Address - Street 1:1450 FARR RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-9770
Practice Address - Country:US
Practice Address - Phone:231-638-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty