NPIMap

Organization Active NPI

Lakeshore Community Health Care, Inc

  • Federally Qualified Health Center (FQHC)
  • Sheboygan, WI
National Provider Identifier
1144698549
Registry record updated Sep 2, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LAKESHORE COMMUNITY HEALTH CARE, INC
Practice address
1721 Saemann Avenue
Sheboygan, WI 53081-2341
Phone
(920) 783-6633
Fax
(920) 783-6392
NPI assigned
Sep 2, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 2, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
David E Hughes
Title
Cfo/Coo
Phone
(920) 783-6633

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

1721 Saemann Avenue
Sheboygan, WI 53081-2341

Mailing address

PO Box 959
Sheboygan, WI 53082-0959
Phone (920) 783-6633

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20121029000074 WI Part A Provider - Federally Qualified Health Center (FQHC) 3173773124 1 other NPI on this enrollment
Practice locations: Sheboygan, WI
O20130605000747 WI Part B Supplier - Clinic/Group Practice 3173773124 Receives reassigned benefits from 46 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Manitowoc, WI; Sheboygan, WI; West Bend, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1144698549. Details of each certification follow.

Federally qualified health center certification: CCN 521845

Legal name
LAKESHORE COMMUNITY HEALTH CARE, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 30, 2012
Last certification
Oct 30, 2012
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 27, 2009 in WI
Enrollment address
1721 Saemann Ave
Sheboygan, WI 53081-2342

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
52D2093182Lakeshore Community Health Care, Inc1721 Saemann Ave, Sheboygan, WI 53081Certificate of waiverMar 22, 2027

National Provider Directory

National Provider Directory
Tax ID family
Lakeshore Community Health6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2719 Calumet Ave
Manitowoc, WI 54220
Phone (920) 686-2333

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kristin D Stearns Individual Corporate OfficerCeo Jun 30, 2013
W-2 Managing EmployeeCeo Jun 30, 2013
Operational/Managerial ControlCeo Jun 30, 2013
Lakeshore Community Health Care, Inc Organization, Sheboygan, WI Corporation, Non-profit Operational/Managerial Control Jun 30, 2013
Caleb a Jensema Individual Corporate OfficerCfo Sep 1, 2021
Operational/Managerial ControlCfo Sep 1, 2021

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1441152000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1441152000000",
    "number": "1144698549",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 959",
            "city": "SHEBOYGAN",
            "state": "WI",
            "postal_code": "530820959",
            "telephone_number": "920-783-6633",
            "fax_number": "920-783-6392"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1721 SAEMANN AVENUE",
            "city": "SHEBOYGAN",
            "state": "WI",
            "postal_code": "530812341",
            "telephone_number": "920-783-6633",
            "fax_number": "920-783-6392"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESHORE COMMUNITY HEALTH CARE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-02",
        "last_updated": "2015-09-02",
        "status": "A",
        "authorized_official_last_name": "HUGHES",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "CFO/COO",
        "authorized_official_telephone_number": "920-783-6633"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sheboygan, WI

Sources for this page

Verify at the official NPI Registry.