Provider Demographics
NPI:1578769527
Name:GREAT LAKES HOME HEALTH CARE , LLC
Entity Type:Organization
Organization Name:GREAT LAKES HOME HEALTH CARE , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - CEO
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:RNBSN
Authorized Official - Phone:586-558-2950
Mailing Address - Street 1:28800 RYAN RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4272
Mailing Address - Country:US
Mailing Address - Phone:586-558-2950
Mailing Address - Fax:586-620-6019
Practice Address - Street 1:28800 RYAN RD
Practice Address - Street 2:SUITE 325
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4272
Practice Address - Country:US
Practice Address - Phone:586-558-2950
Practice Address - Fax:586-620-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI237738OtherMEDICARE NGS