Provider Demographics
NPI:1184304537
Name:GREAT LAKES NET
Entity type:Organization
Organization Name:GREAT LAKES NET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-406-5310
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-0190
Mailing Address - Country:US
Mailing Address - Phone:616-406-5310
Mailing Address - Fax:
Practice Address - Street 1:25 68TH AVE N STE E
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-9223
Practice Address - Country:US
Practice Address - Phone:616-406-5310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)