Provider Demographics
NPI:1700821188
Name:LAKE DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:LAKE DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-626-0766
Mailing Address - Street 1:31800 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 370
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1655
Mailing Address - Country:US
Mailing Address - Phone:248-626-0766
Mailing Address - Fax:248-626-7498
Practice Address - Street 1:3550 PONTIAC LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2337
Practice Address - Country:US
Practice Address - Phone:248-674-8199
Practice Address - Fax:248-674-8205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICOFEGOtherBILLING LOCATOR CODE