Provider Demographics
NPI:1790978666
Name:LAKE COUNTRY PAIN TREATMENT
Entity Type:Organization
Organization Name:LAKE COUNTRY PAIN TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:I
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-257-4673
Mailing Address - Street 1:970 S SILVER LAKE ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 S SILVER LAKE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3802
Practice Address - Country:US
Practice Address - Phone:262-560-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty