Provider Demographics
NPI:1376828228
Name:GREAT LAKES SENIOR CARE, LLC
Entity Type:Organization
Organization Name:GREAT LAKES SENIOR CARE, LLC
Other - Org Name:HOME HELPERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANVLIET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-841-7559
Mailing Address - Street 1:6040 LUTE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5008
Mailing Address - Country:US
Mailing Address - Phone:219-841-7559
Mailing Address - Fax:219-763-4858
Practice Address - Street 1:6040 LUTE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5008
Practice Address - Country:US
Practice Address - Phone:219-841-7559
Practice Address - Fax:219-763-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN110126101320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2010300000 AMedicaid