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General NPI Number Information
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NPI Number | 1639108863
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Entity Type | Organization
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Legal Business Name | LAKESHORE ALLERGY PC
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Dates
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Enumeration Date | 07/01/2006
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Last Update Date | 02/27/2012
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Provider Practice Location Address
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Address Line | 3290 N WELLNESS BLDG D STE 180
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City | HOLLAND
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State | MI
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Zip | 49424
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Country | US
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Telephone | 616-738-4262
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Fax | 616-738-4266
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Provider Business Mailing Address
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Address Line | 3290 N WELLNESS BLDG D STE 180
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City | HOLLAND
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State | MI
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Zip | 49424
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Country | US
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Telephone | 616-738-4262
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Fax | 616-738-4266
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Authorized Official
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Title or Position | OWNER OPERATOR PHYSICIAN
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Name | JULIE ANN HUTSON
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Credential | MD
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Telephone | 616-738-4262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 4301051148
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License Number State | MI
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