Provider Demographics
NPI:1659959450
Name:LAKESHORE COMMUNITY HEALTH CARE, INC.
Entity Type:Organization
Organization Name:LAKESHORE COMMUNITY HEALTH CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-783-6808
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-0959
Mailing Address - Country:US
Mailing Address - Phone:920-783-6633
Mailing Address - Fax:920-783-6392
Practice Address - Street 1:819 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4954
Practice Address - Country:US
Practice Address - Phone:920-783-6633
Practice Address - Fax:920-783-6392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESHORE COMMUNITY HEALTH CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)