Healthcare Provider Details

I. General information

NPI: 1740401017
Provider Name (Legal Business Name): GREEN LAKE MEDICAL SUPPLY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 KERCHEVAL AVE
GROSSE POINTE FARMS MI
48236-3600
US

IV. Provider business mailing address

18530 MACK AVE STE 411
GROSSE POINTE FARMS MI
48236-3254
US

V. Phone/Fax

Practice location:
  • Phone: 313-882-3900
  • Fax: 313-882-3947
Mailing address:
  • Phone: 313-882-3900
  • Fax: 313-882-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. ROBERT LEE MOORHEAD
Title or Position: PRESIDENT
Credential:
Phone: 313-882-3900