Healthcare Provider Details

I. General information

NPI: 1972326163
Provider Name (Legal Business Name): GREAT LAKES ORTHOTICS AND PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 STONEBRIDGE DR
FLINT MI
48532-5407
US

IV. Provider business mailing address

3124 ELK CREEK DR
SWARTZ CREEK MI
48473-8630
US

V. Phone/Fax

Practice location:
  • Phone: 601-594-2801
  • Fax:
Mailing address:
  • Phone: 601-594-2801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: TYNESHIA L MCFARLAND-WILLIAMS
Title or Position: EMPLOYEE
Credential:
Phone: 601-594-2801