Provider Demographics
NPI:1871780858
Name:LAKESIDE OXYGEN SUPPLY, INC.
Entity type:Organization
Organization Name:LAKESIDE OXYGEN SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:NEVEUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-303-0135
Mailing Address - Street 1:19818 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2506
Mailing Address - Country:US
Mailing Address - Phone:313-647-0227
Mailing Address - Fax:313-647-0228
Practice Address - Street 1:19818 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2506
Practice Address - Country:US
Practice Address - Phone:313-647-0227
Practice Address - Fax:313-647-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0942200001Medicare NSC