Provider Demographics
NPI:1922175082
Name:LAKEVIEW DIAGNOSTIC SERVICES
Entity Type:Organization
Organization Name:LAKEVIEW DIAGNOSTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRIDERIKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-293-8700
Mailing Address - Street 1:27727 JOAN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1425
Mailing Address - Country:US
Mailing Address - Phone:586-293-8700
Mailing Address - Fax:586-293-8701
Practice Address - Street 1:21519 HARPER AVE STE 107
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2220
Practice Address - Country:US
Practice Address - Phone:586-293-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MobileGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P24240Medicare ID - Type UnspecifiedGROUP ID NUMBER