NPIMap

Organization Active NPI

Lakeshore Community Health Care, Inc.

  • Federally Qualified Health Center (FQHC)
  • Sheboygan, WI
National Provider Identifier
1659959450
Registry record updated Apr 1, 2021
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
819 Kentucky Ave
Sheboygan, WI 53081-4954
Phone
(920) 783-6633
Fax
(920) 783-6392
NPI assigned
Apr 1, 2021
Organization subpart
Yes
Parent organization
LAKESHORE COMMUNITY HEALTH CARE, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 1, 2021

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

Authorized official

Name
Martin Schaller
Title
Cfo
Phone
(920) 783-6808

Specialties & licenses 1

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

Addresses

Primary practice location

819 Kentucky Ave
Sheboygan, WI 53081-4954

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
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
O20210519002912 WI Part A Provider - Federally Qualified Health Center (FQHC) 3173773124 Practice locations: Sheboygan, WI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1659959450. Details of each certification follow.

Federally qualified health center certification: CCN 521876

Legal name
LAKESHORE COMMUNITY HEALTH CARE, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 15, 2021
Last certification
Jun 15, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 27, 2009 in WI
Enrollment address
819 Kentucky Ave
Sheboygan, WI 53081-4954

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.

National Provider Directory

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

Other organizations with this tax ID 5

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

Ownership & related parties

All disclosed owners & managing parties 2

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 Employee Jun 30, 2013
Operational/Managerial ControlCeo Jun 30, 2013
Caleb a Jensema Individual Corporate OfficerCfo Sep 1, 2021
W-2 Managing EmployeeCfo Sep 1, 2021

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Lakeshore Community Health Care, IncSheboygan, WI, CCN 521845 Federally qualified health center Operational/Managerial Control Jun 30, 2013

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1617235200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1617235200000",
    "number": "1659959450",
    "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": "819 KENTUCKY AVE",
            "city": "SHEBOYGAN",
            "state": "WI",
            "postal_code": "530814954",
            "telephone_number": "920-783-6633",
            "fax_number": "920-783-6392"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESHORE COMMUNITY HEALTH CARE, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LAKESHORE COMMUNITY HEALTH CARE, INC.",
        "enumeration_date": "2021-04-01",
        "last_updated": "2021-04-01",
        "certification_date": "2021-03-09",
        "status": "A",
        "authorized_official_last_name": "SCHALLER",
        "authorized_official_first_name": "MARTIN",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "920-783-6808"
    },
    "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.