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General NPI Number Information
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NPI Number | 1295884930
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ADULT LIVING
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3700 JACKSON ST
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City | GARY
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State | IN
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Zip | 46408-2226
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Country | US
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Telephone | 219-980-1625
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Fax |
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Provider Business Mailing Address
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Address Line | 3843 MADISON ST
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City | GARY
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State | IN
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Zip | 46408-2728
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Country | US
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Telephone | 219-980-1839
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Fax | 219-980-1893
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. GLORIA NKECHI MBANU
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Credential | REGISTER NURSE
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Telephone | 219-980-1625
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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