Provider Demographics
NPI:1720095417
Name:GREAT LAKES DIALYSIS, L.L.C.
Entity Type:Organization
Organization Name:GREAT LAKES DIALYSIS, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BONIFACE
Authorized Official - Middle Name:ATAKEKOR
Authorized Official - Last Name:TUBIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-924-9670
Mailing Address - Street 1:14614 KERCHEVAL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2814
Mailing Address - Country:US
Mailing Address - Phone:313-924-9670
Mailing Address - Fax:313-924-9673
Practice Address - Street 1:14614 KERCHEVAL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2814
Practice Address - Country:US
Practice Address - Phone:313-924-9670
Practice Address - Fax:313-924-9673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072901261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-2614Medicare ID - Type UnspecifiedPROVIDER NUMBER