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General NPI Number Information
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NPI Number | 1124773130
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Entity Type | Organization
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Legal Business Name | LAKESHORE CLINICAL LLC
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Dates
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Enumeration Date | 02/17/2022
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Last Update Date | 02/17/2022
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Provider Practice Location Address
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Address Line | 5411 E STATE ST STE 4
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City | ROCKFORD
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State | IL
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Zip | 61108-2908
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Country | US
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Telephone | 224-310-8328
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Fax |
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Provider Business Mailing Address
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Address Line | 7425 NANTUCKET CV
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City | HANOVER PARK
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State | IL
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Zip | 60133-2720
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Country | US
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Telephone | 224-310-8328
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SETU SHAH
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Credential |
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Telephone | 224-310-8328
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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