1467696153 NPI number — GREAT LAKES IN-HOME CLINICIAN SERVICES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467696153 NPI number — GREAT LAKES IN-HOME CLINICIAN SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES IN-HOME CLINICIAN SERVICES INC
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:
ELITE MEDICAL SERVICES, INC.
Provider Other Organization Name Type Code:
3
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:
1467696153
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
404 W NEPESSING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAPEER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48446-2150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-664-7040
Provider Business Mailing Address Fax Number:
810-245-9080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 S STATE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVISON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48423-1347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-664-7040
Provider Business Practice Location Address Fax Number:
810-245-9080
Provider Enumeration Date:
04/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SURYAVANSHI
Authorized Official First Name:
KAVITA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-245-9400

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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