Provider Demographics
NPI:1023238417
Name:GREAT LAKES SUPPORT SERVICES
Entity type:Organization
Organization Name:GREAT LAKES SUPPORT SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICKIE
Authorized Official - Middle Name:LASHAWN
Authorized Official - Last Name:GRAYS
Authorized Official - Suffix:
Authorized Official - Credentials:NONE
Authorized Official - Phone:231-932-8457
Mailing Address - Street 1:PO BOX 7153
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-7153
Mailing Address - Country:US
Mailing Address - Phone:231-932-8457
Mailing Address - Fax:231-932-8457
Practice Address - Street 1:800 S GARFIELD AVE STE B
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3486
Practice Address - Country:US
Practice Address - Phone:231-932-8457
Practice Address - Fax:231-932-8457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health