Provider Demographics
NPI:1770761272
Name:GREAT LAKES NURSING LLC
Entity type:Organization
Organization Name:GREAT LAKES NURSING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:PRUETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-872-5343
Mailing Address - Street 1:25660 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-2167
Mailing Address - Country:US
Mailing Address - Phone:419-872-5343
Mailing Address - Fax:419-872-7464
Practice Address - Street 1:25660 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2167
Practice Address - Country:US
Practice Address - Phone:419-872-5343
Practice Address - Fax:419-872-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health