Provider Demographics
NPI:1952635302
Name:GREAT LAKES THERAPY AT ORCHARD CREEK CAMPUS
Entity Type:Organization
Organization Name:GREAT LAKES THERAPY AT ORCHARD CREEK CAMPUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:231-642-6166
Mailing Address - Street 1:9731 E CHERRY BEND RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7621
Mailing Address - Country:US
Mailing Address - Phone:231-929-8180
Mailing Address - Fax:
Practice Address - Street 1:1650 BARLOW ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4721
Practice Address - Country:US
Practice Address - Phone:231-941-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT LAKES THERAPY HOUSE CALLS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N83550OtherMEDICARE GROUP
MI0N86360OtherMEDICARE GROUP