Healthcare Provider Details

I. General information

NPI: 1497980759
Provider Name (Legal Business Name): GREAT LAKES MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8153 S 27TH ST
FRANKLIN WI
53132-7012
US

IV. Provider business mailing address

DEPARTMENT 7917
CAROL STREAM IL
60122
US

V. Phone/Fax

Practice location:
  • Phone: 773-885-7696
  • Fax: 773-409-5710
Mailing address:
  • Phone: 773-885-7696
  • Fax: 773-409-5710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN L BOSTANCHE
Title or Position: DIRECTOR
Credential: DPM
Phone: 262-657-3668