1245260371 NPI number — LAKESHORE SPINE AND PAIN P C

Table of content: (NPI 1245260371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245260371 NPI number — LAKESHORE SPINE AND PAIN P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE SPINE AND PAIN P C
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:
LAKESHORE FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
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:
1245260371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5511 W US HIGHWAY 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUDINGTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49431-2455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-843-1553
Provider Business Mailing Address Fax Number:
231-845-5515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5511 W US HIGHWAY 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUDINGTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49431-2455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-843-1553
Provider Business Practice Location Address Fax Number:
231-845-7056
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAKWANA
Authorized Official First Name:
RAJ
Authorized Official Middle Name:
C
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
231-843-1553

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: 700E310160 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com