Healthcare Provider Details

I. General information

NPI: 1841399870
Provider Name (Legal Business Name): LAKESHORE CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 NE 186TH ST
BOTHELL WA
98011-3839
US

IV. Provider business mailing address

PO BOX 646
BOTHELL WA
98041-0646
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-9131
  • Fax: 425-486-9490
Mailing address:
  • Phone: 425-485-3955
  • Fax: 425-485-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA R JEPPESEN
Title or Position: CEO
Credential:
Phone: 425-486-9131