1104365279 NPI number — LAKESIDE ALLERGY ASTHMA AND IMMUNOLOGY LLC

Table of content: (NPI 1104365279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104365279 NPI number — LAKESIDE ALLERGY ASTHMA AND IMMUNOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE ALLERGY ASTHMA AND IMMUNOLOGY LLC
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:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104365279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2227
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30096-0039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-837-5224
Provider Business Mailing Address Fax Number:
404-860-1298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 DULUTH PARK LN STE 820
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-3243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-226-9866
Provider Business Practice Location Address Fax Number:
678-373-3983
Provider Enumeration Date:
02/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ZUO
Authorized Official First Name:
LI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
513-535-0946

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  75964 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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