Healthcare Provider Details

I. General information

NPI: 1720633639
Provider Name (Legal Business Name): GRAND LAKE OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 HAGER STREET
SAINT MARYS OH
45885
US

IV. Provider business mailing address

120 W MAIN ST STE 200
VAN WERT OH
45891-1761
US

V. Phone/Fax

Practice location:
  • Phone: 419-394-3308
  • Fax: 419-394-3300
Mailing address:
  • Phone: 419-238-0715
  • Fax: 419-238-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: EDGAR SILALAHI
Title or Position: CFO
Credential:
Phone: 419-238-0715