Healthcare Provider Details

I. General information

NPI: 1982960316
Provider Name (Legal Business Name): GREAT LAKES PROFESSIONAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22214 FORD RD
DEARBORN HEIGHTS MI
48127-2420
US

IV. Provider business mailing address

22214 FORD RD
DEARBORN HEIGHTS MI
48127-2420
US

V. Phone/Fax

Practice location:
  • Phone: 313-581-1623
  • Fax: 313-581-4683
Mailing address:
  • Phone: 313-581-1623
  • Fax: 313-581-4683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALI SOBH
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 313-581-1623