Provider Demographics
NPI:1841399870
Name:LAKESHORE CLINIC PLLC
Entity Type:Organization
Organization Name:LAKESHORE CLINIC PLLC
Other - Org Name:LAKESHORE CLINIC BOTHELL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:JEPPESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-486-9131
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98041-0646
Mailing Address - Country:US
Mailing Address - Phone:425-485-3955
Mailing Address - Fax:425-485-1476
Practice Address - Street 1:10025 NE 186TH ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3839
Practice Address - Country:US
Practice Address - Phone:425-486-9131
Practice Address - Fax:425-486-9490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0812480003Medicare NSC
217116700Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER