Basic Information
| Provider Information | |||||||||
| NPI: | 1083041297 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKESHORE REGIONAL ENTITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 HAKES DR. | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317692046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 920 DIANA ST | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494311987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318456294 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | LABAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2317692046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.