Provider Demographics
NPI:1902446495
Name:LAKESHORE UNITED LLC
Entity Type:Organization
Organization Name:LAKESHORE UNITED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-421-2730
Mailing Address - Street 1:PO BOX 11180
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-0020
Mailing Address - Country:US
Mailing Address - Phone:480-646-3258
Mailing Address - Fax:
Practice Address - Street 1:4765 S LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7197
Practice Address - Country:US
Practice Address - Phone:480-646-3258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain