| Lakeshore Community Services | |
|
720 W Lake St Ste 105 Minneapolis MN 55408-2963 | |
| (612) 388-9124 | |
| Not Available |
| Full Name | Lakeshore Community Services |
|---|---|
| Speciality | Clinic/Center |
| Location | 720 W Lake St Ste 105, Minneapolis, Minnesota |
| Authorized Official Name and Position | Amir Mohamed (BOARD MEMBER) |
| Authorized Official Contact | 6123889124 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lakeshore Community Services 720 W Lake St Ste 105 Minneapolis MN 55408-2963 Ph: () - | Lakeshore Community Services 720 W Lake St Ste 105 Minneapolis MN 55408-2963 Ph: (612) 388-9124 |
| NPI Number | 1437892403 |
|---|---|
| Provider Enumeration Date | 04/18/2022 |
| Last Update Date | 11/22/2024 |
| Certification Date | 11/22/2024 |
| Medicare PECOS PAC ID | 9335519891 |
|---|---|
| Medicare Enrollment ID | O20221228001810 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437892403 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Secondary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
| Provider Name | Mardiya K Jaffer |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1215436076 PECOS PAC ID: 1254695042 Enrollment ID: I20180502001710 |
| Provider Name | Miteku Tezera Desalgne |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164028296 PECOS PAC ID: 8820471899 Enrollment ID: I20220824001667 |
| Provider Name | Shirlynn Mc Neil La Chapelle |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306593710 PECOS PAC ID: 4385179779 Enrollment ID: I20241121003175 |
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