Provider Demographics
NPI:1922052422
Name:LAKESHORE CLINIC PLLC
Entity Type:Organization
Organization Name:LAKESHORE CLINIC PLLC
Other - Org Name:
Other - Org Type:
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:425-485-3955
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 1:10131 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3425
Practice Address - Country:US
Practice Address - Phone:425-485-3955
Practice Address - Fax:425-485-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG217116700OtherPTAN
WA217116700Medicare UPIN