# LAKE COUNTRY ENDOSCOPY CENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1184897472
- **Authorized official:** BAO XIONG THAO (AUTHORIZED OFFICIAL)
- **Authorized official phone:** (414) 908-6506

## Contact information

- **Practice address:** 1185 CORPORATE CENTER DR, SUITE 125, OCONOMOWOC, WI 53066-4845
- **Practice address phone:** (414) 454-0600
- **Practice address fax:** (414) 454-0971
- **Mailing address:** 2801 W KINNICKINNIC RIVER PKWY STE 1080, MILWAUKEE, WI 53215-3689
- **Mailing address phone:** (414) 908-6615
- **Mailing address fax:** (414) 908-6634

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 04/08/2008
- **Last updated:** 01/08/2025