1801238787 NPI number — LAKESHORE PEDIATRICS PC

Table of content: (NPI 1801238787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801238787 NPI number — LAKESHORE PEDIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE PEDIATRICS 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:
1801238787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 S JACKSON HWY STE 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHEFFIELD
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35660-5773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-386-4151
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12521 AL HIGHWAY 157 STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOULTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35650-1937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-974-6300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RIVAS
Authorized Official First Name:
AGUSTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
256-386-4151

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  17108 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1588002455 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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