Healthcare Provider Details

I. General information

NPI: 1205240686
Provider Name (Legal Business Name): LAKESHORE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 S 20TH ST SUITE 100
MILWAUKEE WI
53215-4940
US

IV. Provider business mailing address

3305 S 20TH ST SUITE 100
MILWAUKEE WI
53215-4940
US

V. Phone/Fax

Practice location:
  • Phone: 414-645-1808
  • Fax:
Mailing address:
  • Phone: 414-645-1808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number178111-30
License Number StateWI

VIII. Authorized Official

Name: FRANK LAVORA
Title or Position: PODIATRIST
Credential: DPM
Phone: 414-768-5430