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General NPI Number Information
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NPI Number | 1902446495
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Entity Type | Organization
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Legal Business Name | LAKESHORE UNITED LLC
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Dates
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Enumeration Date | 01/13/2020
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Last Update Date | 01/13/2020
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Provider Practice Location Address
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Address Line | 4765 S LAKESHORE DR
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City | TEMPE
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State | AZ
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Zip | 85282-7197
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Country | US
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Telephone | 480-646-3258
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11180
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City | TEMPE
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State | AZ
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Zip | 85284-0020
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Country | US
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Telephone | 480-646-3258
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | JEREMY BUCKNER
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Credential | DC
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Telephone | 602-421-2730
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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