Healthcare Provider Details

I. General information

NPI: 1730430703
Provider Name (Legal Business Name): LAKESHORE PREMIUM HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N HALSTED ST SUITE 609
CHICAGO IL
60657-5188
US

IV. Provider business mailing address

3000 N HALSTED ST SUITE 609
CHICAGO IL
60657-5188
US

V. Phone/Fax

Practice location:
  • Phone: 949-584-2059
  • Fax: 949-679-9174
Mailing address:
  • Phone: 949-584-2059
  • Fax: 949-679-9174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number036-131263
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-131263
License Number StateIL

VIII. Authorized Official

Name: DR. JULIE THOMAS
Title or Position: PHYSICIAN
Credential: MD
Phone: 949-584-2059