Provider Demographics
NPI:1184897472
Name:LAKE COUNTRY ENDOSCOPY CENTER, LLC
Entity type:Organization
Organization Name:LAKE COUNTRY ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BAO
Authorized Official - Middle Name:
Authorized Official - Last Name:XIONG THAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-908-6506
Mailing Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 1080
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3689
Mailing Address - Country:US
Mailing Address - Phone:414-908-6615
Mailing Address - Fax:414-908-6634
Practice Address - Street 1:1185 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 125
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4845
Practice Address - Country:US
Practice Address - Phone:414-454-0600
Practice Address - Fax:414-454-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184897472Medicaid
WI1184897472Medicaid