Provider Demographics
NPI:1154470334
Name:GREAT LAKES HEARING
Entity Type:Organization
Organization Name:GREAT LAKES HEARING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:FAASSE'
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-988-4327
Mailing Address - Street 1:6272 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6902
Mailing Address - Country:US
Mailing Address - Phone:616-988-4327
Mailing Address - Fax:616-988-9070
Practice Address - Street 1:6272 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6902
Practice Address - Country:US
Practice Address - Phone:616-988-4327
Practice Address - Fax:616-988-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501000421332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0004271683Medicaid