Provider Demographics
NPI:1740401017
Name:GREEN LAKE MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:GREEN LAKE MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MOORHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-882-3900
Mailing Address - Street 1:18530 MACK AVE STE 411
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3254
Mailing Address - Country:US
Mailing Address - Phone:313-882-3900
Mailing Address - Fax:313-882-3947
Practice Address - Street 1:93 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3600
Practice Address - Country:US
Practice Address - Phone:313-882-3900
Practice Address - Fax:313-882-3947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3141989Medicaid
MI3141989Medicaid