Healthcare Provider Details

I. General information

NPI: 1073028890
Provider Name (Legal Business Name): LAKESHORE MEDICAL TRANSPORT AND SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11450 MINDEN ST
DETROIT MI
48205-3763
US

IV. Provider business mailing address

11450 MINDEN ST
DETROIT MI
48205-3763
US

V. Phone/Fax

Practice location:
  • Phone: 313-437-3841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name: DONTE ROBERTS
Title or Position: PRESIDENT
Credential:
Phone: 313-329-8125