Organization
LAKE COUNTRY ENDOSCOPY CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BAO XIONG THAO (AUTHORIZED OFFICIAL)
(414) 908-6506
Entity
Organization
Contact information
Practice address
1185 CORPORATE CENTER DR, SUITE 125, OCONOMOWOC, WI 53066-4845
(414) 454-0600
(414) 454-0971
Mailing address
2801 W KINNICKINNIC RIVER PKWY STE 1080, MILWAUKEE, WI 53215-3689
(414) 908-6615
(414) 908-6634
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1184897472
—
WI
Enumeration date
04/08/2008
Last updated
01/08/2025
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