1568642791 NPI number — LAKESHORE INTEGRATIVE HEALTHCARE, LTD

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 1568642791 NPI number — LAKESHORE INTEGRATIVE HEALTHCARE, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE INTEGRATIVE HEALTHCARE, LTD
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:
DANIEL E VARANAUSKI, DN PC
Provider Other Organization Name Type Code:
4
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:
1568642791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2731 N SEMINARY AVE
Provider Second Line Business Mailing Address:
STE #1
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60614-1322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-972-6566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2202 N LINCOLN AVE
Provider Second Line Business Practice Location Address:
STE #1
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-7170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-698-9855
Provider Business Practice Location Address Fax Number:
312-698-9857
Provider Enumeration Date:
11/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VARANAUSKI
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
773-972-6566

Provider Taxonomy Codes

  • Taxonomy code: 133N00000X , with the licence number:  181-000304 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 172P00000X , with the licence number: 181-000304 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 070010058 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01633587 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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