Provider Demographics
NPI:1275123200
Name:GREEN LAKES LLC
Entity Type:Organization
Organization Name:GREEN LAKES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:FOLARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEDEJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-888-5040
Mailing Address - Street 1:277 COON RAPIDS BLVD NW STE 414
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5865
Mailing Address - Country:US
Mailing Address - Phone:612-888-5040
Mailing Address - Fax:612-688-7440
Practice Address - Street 1:277 COON RAPIDS BLVD NW STE 414
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5865
Practice Address - Country:US
Practice Address - Phone:612-888-5040
Practice Address - Fax:612-688-7440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-23
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health