Provider Demographics
NPI:1679254700
Name:LAKEVIEW HEALTH, LLC
Entity type:Organization
Organization Name:LAKEVIEW HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-498-0432
Mailing Address - Street 1:800 GOOLD ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4567
Mailing Address - Country:US
Mailing Address - Phone:262-456-2182
Mailing Address - Fax:262-456-2457
Practice Address - Street 1:800 GOOLD ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4567
Practice Address - Country:US
Practice Address - Phone:262-456-2182
Practice Address - Fax:262-456-2457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty