Provider Demographics
NPI:1861686867
Name:GREAT LAKES REHABILITATION LLC
Entity Type:Organization
Organization Name:GREAT LAKES REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIMPLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AGGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR,CLT
Authorized Official - Phone:248-982-2320
Mailing Address - Street 1:34914 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-4614
Mailing Address - Country:US
Mailing Address - Phone:248-982-2320
Mailing Address - Fax:
Practice Address - Street 1:34914 VALLEY FORGE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-4614
Practice Address - Country:US
Practice Address - Phone:248-982-2320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-01
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000642225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty