Provider Demographics
NPI:1124773130
Name:LAKESHORE CLINICAL LLC
Entity type:Organization
Organization Name:LAKESHORE CLINICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SETU
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-310-8328
Mailing Address - Street 1:7425 NANTUCKET CV
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-2720
Mailing Address - Country:US
Mailing Address - Phone:224-310-8328
Mailing Address - Fax:
Practice Address - Street 1:5411 E STATE ST STE 4
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2908
Practice Address - Country:US
Practice Address - Phone:224-310-8328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory