1639108863 NPI number — LAKESHORE ALLERGY PC

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 1639108863 NPI number — LAKESHORE ALLERGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE ALLERGY PC
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:
1639108863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3290 N WELLNESS
Provider Second Line Business Mailing Address:
BLDG D STE 180
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-738-4262
Provider Business Mailing Address Fax Number:
616-738-4266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3290 N WELLNESS
Provider Second Line Business Practice Location Address:
BLDG D STE 180
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-738-4262
Provider Business Practice Location Address Fax Number:
616-738-4266
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUTSON
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER OPERATOR PHYSICIAN
Authorized Official Telephone Number:
616-738-4262

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  4301051148 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0030084 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P105210 . This is a "BLUECH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4604806 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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