Provider Demographics
NPI:1295111227
Name:GREAT LAKES PERSONAL CARE SERVICES LLC
Entity type:Organization
Organization Name:GREAT LAKES PERSONAL CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-954-5727
Mailing Address - Street 1:2158 45TH ST
Mailing Address - Street 2:#245
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-3742
Mailing Address - Country:US
Mailing Address - Phone:877-954-5727
Mailing Address - Fax:866-941-6921
Practice Address - Street 1:2009 W GLEN PARK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-3735
Practice Address - Country:US
Practice Address - Phone:877-954-5727
Practice Address - Fax:866-941-6921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN140129981251G00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201147030AOtherLEGACY PROVIDER ID / LPI
IN201147030AMedicaid