Provider Demographics
NPI:1881074961
Name:GREEN LAKE OPCO, LLC
Entity type:Organization
Organization Name:GREEN LAKE OPCO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISREAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-440-2660
Mailing Address - Street 1:3755 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-4008
Mailing Address - Country:US
Mailing Address - Phone:847-440-2660
Mailing Address - Fax:
Practice Address - Street 1:6470 ALDEN DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-2006
Practice Address - Country:US
Practice Address - Phone:248-363-4121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1881074961Medicaid
MI235489Medicare Oscar/Certification