Healthcare Provider Details

I. General information

NPI: 1649632191
Provider Name (Legal Business Name): LAKESHORE COMMUNITY OUTREACH INCORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 CLINTON ST
GARY IN
46406-1453
US

IV. Provider business mailing address

730 CLINTON ST
GARY IN
46406-1453
US

V. Phone/Fax

Practice location:
  • Phone: 219-588-4511
  • Fax: 219-898-2045
Mailing address:
  • Phone: 219-588-4511
  • Fax: 219-898-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MS. GLADYS FRYE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 219-588-4511