Provider Demographics
NPI:1487998829
Name:LAKESHORE PROFESSIONAL LLC
Entity type:Organization
Organization Name:LAKESHORE PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-571-4179
Mailing Address - Street 1:3375 MERRIAM ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3173
Mailing Address - Country:US
Mailing Address - Phone:231-571-4179
Mailing Address - Fax:231-720-0501
Practice Address - Street 1:3375 MERRIAM ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3173
Practice Address - Country:US
Practice Address - Phone:231-571-4179
Practice Address - Fax:231-720-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health