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General NPI Number Information
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NPI Number | 1568895027
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Entity Type | Organization
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Legal Business Name | LAKESIDE TRANSPORT GROUP, INC
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Dates
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Enumeration Date | 08/19/2013
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Last Update Date | 08/19/2013
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Provider Practice Location Address
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Address Line | 24724 FARMBROOK RD
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City | SOUTHFIELD
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State | MI
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Zip | 48034-1211
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Country | US
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Telephone | 248-228-2266
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Fax |
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Provider Business Mailing Address
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Address Line | 24724 FARMBROOK RD
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City | SOUTHFIELD
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State | MI
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Zip | 48034-1211
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Country | US
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Telephone | 248-228-2266
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. DOMONIQUE CLEMENTS
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Credential |
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Telephone | 248-228-2266
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 347E00000X
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Taxonomy Name | Transportation Broker
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License Number | L1582
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License Number State | MI
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