MEDICARE: LAKE SHORE TREATEMENT CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	1067244	MN

General Provider Information

NPI Number	:	1023430519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE TREATEMENT CENTER LLC

Provider Business Mailing Address
First Line	:	550 MAIN ST STE 230
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-3274
Country	:	US
Telephone Number	:	612-326-7600
Fax Number	:	651-631-3231

Provider Business Practice Location Address
First Line	:	140 QUAIL ST
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-1941
Country	:	US
Telephone Number	:	612-326-7600
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LEWIS P ZEIDNER
Credential	:	PHD
Telephone Number	:	763-245-8278

Provider Enumeration Date	:	01/17/2014
Last Update Date	:	02/20/2025

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