Basic Information
| Provider Information | |||||||||
| NPI: | 1205240686 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESHORE MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3305 S 20TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146451808 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3305 S 20TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146451808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | LAVORA | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PODIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 4147685430 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 178111-30 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.