Provider Demographics
NPI:1639374036
Name:LAKESHORE MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BANIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-744-6589
Mailing Address - Street 1:331 E PUETZ RD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-3254
Mailing Address - Country:US
Mailing Address - Phone:414-570-3590
Mailing Address - Fax:
Practice Address - Street 1:331 E PUETZ RD
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-3254
Practice Address - Country:US
Practice Address - Phone:414-570-3590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0458040010Medicare NSC