Provider Demographics
NPI:1093069734
Name:GREAT LAKES THERAPY HOUSECALLS, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES THERAPY HOUSECALLS, P.C.
Other - Org Name:GREAT LAKES PHYSICAL THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:231-941-8100
Mailing Address - Street 1:3281 RACQUET CLUB DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4701
Mailing Address - Country:US
Mailing Address - Phone:231-941-8100
Mailing Address - Fax:231-941-8812
Practice Address - Street 1:9731 E CHERRY BEND RD
Practice Address - Street 2:STE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7621
Practice Address - Country:US
Practice Address - Phone:231-941-8100
Practice Address - Fax:231-995-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236863Medicare Oscar/Certification