Provider Demographics
NPI:1962653378
Name:GREAT LAKES PHYSICAL THERAPIES, LLC
Entity Type:Organization
Organization Name:GREAT LAKES PHYSICAL THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LINK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEPHOUSE
Authorized Official - Suffix:SR
Authorized Official - Credentials:PT
Authorized Official - Phone:616-842-5555
Mailing Address - Street 1:921 S BEECHTREE ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2385
Mailing Address - Country:US
Mailing Address - Phone:616-842-0555
Mailing Address - Fax:
Practice Address - Street 1:921 S BEECHTREE ST
Practice Address - Street 2:SUITE 5
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2385
Practice Address - Country:US
Practice Address - Phone:616-842-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011546261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1390Medicare PIN