Provider Demographics
NPI:1669614152
Name:GREAT LAKES MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:GREAT LAKES MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SCHRECKENGUST
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:269-925-8386
Mailing Address - Street 1:1850 PIPESTONE RD
Mailing Address - Street 2:SUITE 102-B
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2304
Mailing Address - Country:US
Mailing Address - Phone:269-925-8386
Mailing Address - Fax:269-925-4085
Practice Address - Street 1:1850 PIPESTONE RD
Practice Address - Street 2:SUITE 102-B
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2304
Practice Address - Country:US
Practice Address - Phone:269-925-8386
Practice Address - Fax:269-925-4085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002947261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care