Provider Demographics
NPI:1295884930
Name:GREAT LAKES ADULT LIVING
Entity type:Organization
Organization Name:GREAT LAKES ADULT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:NKECHI
Authorized Official - Last Name:MBANU
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTER NURSE
Authorized Official - Phone:219-980-1625
Mailing Address - Street 1:3843 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-2728
Mailing Address - Country:US
Mailing Address - Phone:219-980-1839
Mailing Address - Fax:219-980-1893
Practice Address - Street 1:3700 JACKSON ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-2226
Practice Address - Country:US
Practice Address - Phone:219-980-1625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health