Provider Demographics
NPI:1952565970
Name:GREAT LAKE HOME CARE L L C
Entity Type:Organization
Organization Name:GREAT LAKE HOME CARE L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-537-5848
Mailing Address - Street 1:17070 W 12 MILE RD
Mailing Address - Street 2:STE D
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2116
Mailing Address - Country:US
Mailing Address - Phone:313-537-5848
Mailing Address - Fax:248-987-6919
Practice Address - Street 1:30800 TELEGRAPH RD STE 2815
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4544
Practice Address - Country:US
Practice Address - Phone:313-537-5848
Practice Address - Fax:248-987-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health