Provider Demographics
NPI:1134363450
Name:LAKEVIEW HOME DIALYSIS LLC
Entity type:Organization
Organization Name:LAKEVIEW HOME DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:MEDHAT
Authorized Official - Last Name:SALEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-525-4701
Mailing Address - Street 1:331 W SURF ST STE 703
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7227
Mailing Address - Country:US
Mailing Address - Phone:773-525-4701
Mailing Address - Fax:773-326-3539
Practice Address - Street 1:331 W SURF ST STE 703
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7227
Practice Address - Country:US
Practice Address - Phone:773-525-3053
Practice Address - Fax:773-326-3539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-30
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14-2724OtherCMS CERTIFICATION NUMBER