Healthcare Provider Details

I. General information

NPI: 1831351873
Provider Name (Legal Business Name): GREAT LAKES HEALTH & WELLNESS,SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 W COLLEGE DR STE 1SW
PALOS HEIGHTS IL
60463-1393
US

IV. Provider business mailing address

7250 W COLLEGE DR STE 1SW
PALOS HEIGHTS IL
60463-1393
US

V. Phone/Fax

Practice location:
  • Phone: 708-371-6114
  • Fax: 708-371-0816
Mailing address:
  • Phone: 708-371-6114
  • Fax: 708-371-0816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.008605
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARY PETERSON
Title or Position: PRESIDENT
Credential: DC
Phone: 708-574-0736