Healthcare Provider Details

I. General information

NPI: 1568642791
Provider Name (Legal Business Name): LAKESHORE INTEGRATIVE HEALTHCARE, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 N LINCOLN AVE STE #1
CHICAGO IL
60614-7170
US

IV. Provider business mailing address

2731 N SEMINARY AVE STE #1
CHICAGO IL
60614-1322
US

V. Phone/Fax

Practice location:
  • Phone: 312-698-9855
  • Fax: 312-698-9857
Mailing address:
  • Phone: 773-972-6566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number181-000304
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number181-000304
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070010058
License Number StateIL

VIII. Authorized Official

Name: DR. DANIEL E VARANAUSKI
Title or Position: DIRECTOR
Credential: D.N.
Phone: 773-972-6566