Provider Demographics
NPI:1760665301
Name:LAKESHORE MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:LAKESHORE MEDICAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:E
Authorized Official - Last Name:NWEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-855-2279
Mailing Address - Street 1:9550 FOREST LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5905
Mailing Address - Country:US
Mailing Address - Phone:214-348-9700
Mailing Address - Fax:214-348-9701
Practice Address - Street 1:9550 FOREST LN
Practice Address - Street 2:SUITE 102
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5905
Practice Address - Country:US
Practice Address - Phone:214-348-9700
Practice Address - Fax:214-348-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6104570001Medicare NSC