Provider Demographics
NPI:1184485963
Name:GREAT LAKES MEDICAL DEVICES
Entity type:Organization
Organization Name:GREAT LAKES MEDICAL DEVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-701-6418
Mailing Address - Street 1:3196 S IRISH RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-2434
Mailing Address - Country:US
Mailing Address - Phone:810-701-6418
Mailing Address - Fax:
Practice Address - Street 1:105 E 2ND ST UNIT H
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1467
Practice Address - Country:US
Practice Address - Phone:810-447-0135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies