Provider Demographics
NPI:1205433778
Name:GREAT LAKES HOSPICE LLC
Entity type:Organization
Organization Name:GREAT LAKES HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOEHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-962-5250
Mailing Address - Street 1:5150 N PORT WASHINGTON RD STE 152
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5453
Mailing Address - Country:US
Mailing Address - Phone:414-885-0909
Mailing Address - Fax:414-885-0922
Practice Address - Street 1:5150 N PORT WASHINGTON RD STE 152
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5453
Practice Address - Country:US
Practice Address - Phone:262-349-5753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based