1184897472 NPI number — LAKE COUNTRY ENDOSCOPY CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184897472 NPI number — LAKE COUNTRY ENDOSCOPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE COUNTRY ENDOSCOPY CENTER, 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184897472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 W KINNICKINNIC RIVER PKWY STE 1080
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53215-3689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-908-6615
Provider Business Mailing Address Fax Number:
414-908-6634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1185 CORPORATE CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
OCONOMOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53066-4845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-454-0600
Provider Business Practice Location Address Fax Number:
414-454-0971
Provider Enumeration Date:
04/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
XIONG THAO
Authorized Official First Name:
BAO
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
414-908-6506

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1184897472 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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