Provider Demographics
NPI:1629465794
Name:GREAT LAKES HEALTHCARE OF OHIO, LLC
Entity Type:Organization
Organization Name:GREAT LAKES HEALTHCARE OF OHIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:330-472-0372
Mailing Address - Street 1:9350 S PADRE ISLAND DR APT 113
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-5514
Mailing Address - Country:US
Mailing Address - Phone:330-472-0372
Mailing Address - Fax:
Practice Address - Street 1:2494 MAPLEHURST DR
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-2755
Practice Address - Country:US
Practice Address - Phone:330-472-0372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health