1134130172 NPI number — LAKE DIAGNOSTICS, INC.

Table of content: (NPI 1134130172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134130172 NPI number — LAKE DIAGNOSTICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE DIAGNOSTICS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134130172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3550 PONTIAC LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48328-2337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-674-8199
Provider Business Mailing Address Fax Number:
248-674-8205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 PONTIAC LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48328-2337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-674-8199
Provider Business Practice Location Address Fax Number:
248-674-8205
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEIB
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
248-674-8199

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4168987-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376540286 . This is a "NPI KACHADURIAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3175190-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1437181146 . This is a "NPI MELLEN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1891751509 . This is a "NPI KOVAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4661544-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4876314-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1205824505 . This is a "NPI RUBIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3225247-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA2712 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1346212800 . This is a "NPI BORIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1356349062 . This is a "NPI SILVERMAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1013935071 . This is a "NPI OSTERBERGER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1588661391 . This is a "NPI ELKISS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700F313270 . This is a "BCBS GROUP PROVIDER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4876216-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com