Provider Demographics
NPI:1669968129
Name:LAKE SHORE AFC, LLC
Entity type:Organization
Organization Name:LAKE SHORE AFC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SCHOLTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-276-9260
Mailing Address - Street 1:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:GRAWN
Mailing Address - State:MI
Mailing Address - Zip Code:49637-0119
Mailing Address - Country:US
Mailing Address - Phone:231-276-9260
Mailing Address - Fax:231-276-9380
Practice Address - Street 1:2480 TONAWANDA LAKE RD
Practice Address - Street 2:
Practice Address - City:GRAWN
Practice Address - State:MI
Practice Address - Zip Code:49637-9615
Practice Address - Country:US
Practice Address - Phone:231-276-9260
Practice Address - Fax:231-276-9380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM2802899263104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances