Provider Demographics
NPI:1952175614
Name:LAKEWOOD CHILDREN'S CLINIC LLC
Entity Type:Organization
Organization Name:LAKEWOOD CHILDREN'S CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-957-2273
Mailing Address - Street 1:8 LAKETREE CT
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-5679
Mailing Address - Country:US
Mailing Address - Phone:917-957-2273
Mailing Address - Fax:
Practice Address - Street 1:8 LAKETREE CT
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NJ
Practice Address - Zip Code:08759-5679
Practice Address - Country:US
Practice Address - Phone:917-957-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center