1033642715 NPI number — GREAT LAKES LIVING SOLUTIONS CORP.

Table of content: (NPI 1033642715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033642715 NPI number — GREAT LAKES LIVING SOLUTIONS CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES LIVING SOLUTIONS CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033642715
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
477 E. BUTTERFIELD RD.
Provider Second Line Business Mailing Address:
SUITE LL005
Provider Business Mailing Address City Name:
LOMBARD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-426-1099
Provider Business Mailing Address Fax Number:
630-519-1310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
477 E. BUTTERFIELD RD.
Provider Second Line Business Practice Location Address:
SUITE LL005
Provider Business Practice Location Address City Name:
LOMBARD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-426-1099
Provider Business Practice Location Address Fax Number:
630-519-1310
Provider Enumeration Date:
04/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
FRISCIA
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
ADMINISTRATOR/OWNER
Authorized Official Telephone Number:
630-426-1356

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: 3001497 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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