Organization
LAKE SHORE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JUDITH A DEERY RN (BUSINESS MANAGER)
(574) 842-3327
Entity
Organization
Contact information
Practice address
921 N LAKE SHORE DR, CULVER, IN 46511-1207
(574) 842-4330
Mailing address
921 N LAKE SHORE DR, CULVER, IN 46511-1207
(574) 842-4330
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
207Q000000X
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
15D0356500
CLIA NUMBER
IN
01
—
207Q000000X
TAXONOMY
IN
Enumeration date
03/16/2007
Last updated
06/21/2018
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