Provider Demographics
NPI:1629370663
Name:GREAT LAKES THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:GREAT LAKES THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHARRARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-326-0929
Mailing Address - Street 1:3491 S HURON RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-1547
Mailing Address - Country:US
Mailing Address - Phone:989-326-0929
Mailing Address - Fax:989-488-4444
Practice Address - Street 1:3491 S HURON RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-1547
Practice Address - Country:US
Practice Address - Phone:989-667-6469
Practice Address - Fax:989-488-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4969Medicare PIN