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General NPI Number Information
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NPI Number | 1043728553
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Entity Type | Organization
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Legal Business Name | GREAT LAKES PODIATRY PLLC
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Dates
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Enumeration Date | 01/18/2018
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Last Update Date | 01/18/2018
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Provider Practice Location Address
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Address Line | 126 S 25TH ST STE A
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City | ESCANABA
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State | MI
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Zip | 49829-1364
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Country | US
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Telephone | 906-786-2385
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Fax | 906-563-2029
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Provider Business Mailing Address
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Address Line | W4042 LAKE MARY DR S
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City | VULCAN
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State | MI
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Zip | 49892-8452
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Country | US
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Telephone | 906-280-5396
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Fax |
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Authorized Official
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Title or Position | OWNER/PODIATRIST
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Name | DENNIS W LEVEILLE
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Credential | DPM
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Telephone | 906-786-2385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 5901001228
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 5901001228
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License Number State | MI
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