Provider Demographics
NPI:1629111943
Name:LAKESHORES OUTPATIENT CLINIC
Entity Type:Organization
Organization Name:LAKESHORES OUTPATIENT CLINIC
Other - Org Name:BROTOLOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBEAUX-STINSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:262-656-9975
Mailing Address - Street 1:3917 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1956
Mailing Address - Country:US
Mailing Address - Phone:262-656-9975
Mailing Address - Fax:262-656-9974
Practice Address - Street 1:3917 47TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1956
Practice Address - Country:US
Practice Address - Phone:262-656-9975
Practice Address - Fax:262-656-9974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2605261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42242400Medicaid
WI44810Medicare ID - Type UnspecifiedMEDICARE NUMBER