Healthcare Provider Details

I. General information

NPI: 1922175082
Provider Name (Legal Business Name): LAKEVIEW DIAGNOSTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21519 HARPER AVE STE 107
SAINT CLAIR SHORES MI
48080-2220
US

IV. Provider business mailing address

27727 JOAN ST
SAINT CLAIR SHORES MI
48081-1425
US

V. Phone/Fax

Practice location:
  • Phone: 586-293-8700
  • Fax:
Mailing address:
  • Phone: 586-293-8700
  • Fax: 586-293-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FRIDERIKI MANTIS
Title or Position: PRESIDENT
Credential:
Phone: 586-293-8700