Healthcare Provider Details

I. General information

NPI: 1497983837
Provider Name (Legal Business Name): LAKESHORE MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 W OAKWOOD PARK CT
FRANKLIN WI
53132-8131
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-423-5250
  • Fax:
Mailing address:
  • Phone: 414-647-6326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BANIA
Title or Position: SENIOR DIRECTOR
Credential:
Phone: 414-766-9094