Provider Demographics
NPI:1316217219
Name:GREAT LAKES HOME CARE INC.
Entity Type:Organization
Organization Name:GREAT LAKES HOME CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY-KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:EGERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-537-6651
Mailing Address - Street 1:6000 BASS LAKE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2753
Mailing Address - Country:US
Mailing Address - Phone:763-537-6651
Mailing Address - Fax:763-535-4288
Practice Address - Street 1:6000 BASS LAKE RD STE 104
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-2753
Practice Address - Country:US
Practice Address - Phone:763-537-6651
Practice Address - Fax:763-535-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN353271251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA838495100OtherPCPO
MNA697120000Medicaid
MN353271OtherCLASS A