Provider Demographics
NPI:1649710823
Name:GREAT LAKES PROVIDER NETWORK, LLC
Entity type:Organization
Organization Name:GREAT LAKES PROVIDER NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEFFERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-944-0043
Mailing Address - Street 1:33900 HARPER AVE STE A101
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-359-2649
Mailing Address - Fax:844-522-5038
Practice Address - Street 1:33900 HARPER AVE STE A101
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-4258
Practice Address - Country:US
Practice Address - Phone:586-359-2649
Practice Address - Fax:844-522-5038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUDIONET AMERICA HOLDINGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty