Provider Demographics
NPI:1811324619
Name:GREAT LAKES WELLNESS SERVICES
Entity type:Organization
Organization Name:GREAT LAKES WELLNESS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CAMPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-588-7444
Mailing Address - Street 1:1 EMERALD POINTE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451
Mailing Address - Country:US
Mailing Address - Phone:810-588-7444
Mailing Address - Fax:
Practice Address - Street 1:1 EMERALD POINTE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451
Practice Address - Country:US
Practice Address - Phone:810-588-7444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service