Provider Demographics
NPI:1679705354
Name:GREAT LAKES HOME DOCTORS PC
Entity Type:Organization
Organization Name:GREAT LAKES HOME DOCTORS PC
Other - Org Name:PATIENT CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUNDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTSKOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-978-2343
Mailing Address - Street 1:1160 VILLA CT N
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3376
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1160 VILLA CT N
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3376
Practice Address - Country:US
Practice Address - Phone:313-978-2343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty