Provider Demographics
NPI:1124401625
Name:GREAT LAKES PHYSICAL THERAPY AND REHABILITATION LLC
Entity Type:Organization
Organization Name:GREAT LAKES PHYSICAL THERAPY AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:STAPELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-321-4563
Mailing Address - Street 1:12434 E 12 MILE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3536
Mailing Address - Country:US
Mailing Address - Phone:586-578-9121
Mailing Address - Fax:586-578-9124
Practice Address - Street 1:12434 E 12 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3536
Practice Address - Country:US
Practice Address - Phone:586-578-9121
Practice Address - Fax:586-578-9124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIE6533E261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
12434OtherADDRESS