Provider Demographics
NPI:1962845040
Name:LAKESHORE GERIATRIC CARE GROUP
Entity Type:Organization
Organization Name:LAKESHORE GERIATRIC CARE GROUP
Other - Org Name:LAKESHORE ADULT DAY HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-960-0646
Mailing Address - Street 1:829 ASBURY DR STE 3
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6512
Mailing Address - Country:US
Mailing Address - Phone:985-778-0736
Mailing Address - Fax:
Practice Address - Street 1:829 ASBURY DR STE 3
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6512
Practice Address - Country:US
Practice Address - Phone:985-778-0736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203781570261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care