# VINCENT A GRASER

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lakeside Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1740365378
- **Authorized official:** VINCENT A GRASER MSSAD (CLINICAL SOCIAL WORKER)
- **Authorized official phone:** (920) 458-9434

## Contact information

- **Practice address:** 833 PENNSYLVANIA AVE, SUITE 103, SHEBOYGAN, WI 53081-4452
- **Practice address phone:** (920) 458-9434
- **Practice address fax:** (920) 458-6313
- **Mailing address:** 833 PENNSYLVANIA AVE., PO BOX 1143, SHEBOYGAN, WI 53082-1143
- **Mailing address phone:** (920) 458-9434
- **Mailing address fax:** (920) 458-6313

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | 1501 | WI | Yes |

## Other

- **Enumeration date:** 10/25/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 42126500 | — | WI |