Provider Demographics
NPI:1720633639
Name:GRAND LAKE OPERATIONS, LLC
Entity Type:Organization
Organization Name:GRAND LAKE OPERATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPA/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCCLEERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-238-0715
Mailing Address - Street 1:120 W MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-1761
Mailing Address - Country:US
Mailing Address - Phone:419-238-0715
Mailing Address - Fax:419-238-4814
Practice Address - Street 1:1035 HAGER STREET
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885
Practice Address - Country:US
Practice Address - Phone:419-394-3308
Practice Address - Fax:419-394-3300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-07
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility