Healthcare Provider Details

I. General information

NPI: 1881357192
Provider Name (Legal Business Name): GREAT LAKES RESEARCH INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20755 GREENFIELD RD
SOUTHFIELD MI
48075-5403
US

IV. Provider business mailing address

20755 GREENFIELD RD
SOUTHFIELD MI
48075-5403
US

V. Phone/Fax

Practice location:
  • Phone: 248-864-5242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name: DIANA ALEXANDRIA
Title or Position: HEALTHCARE CONSULTANT
Credential:
Phone: 313-920-5522