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General NPI Number Information
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NPI Number | 1316217219
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Entity Type | Organization
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Legal Business Name | GREAT LAKES HOME CARE INC.
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Dates
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Enumeration Date | 01/09/2012
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Last Update Date | 01/09/2012
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Provider Practice Location Address
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Address Line | 6000 BASS LAKE RD STE 104
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City | CRYSTAL
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State | MN
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Zip | 55429-2753
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Country | US
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Telephone | 763-537-6651
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Fax | 763-535-4288
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Provider Business Mailing Address
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Address Line | 6000 BASS LAKE RD STE 104
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City | CRYSTAL
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State | MN
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Zip | 55429-2753
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Country | US
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Telephone | 763-537-6651
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Fax | 763-535-4288
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. MARY-KIM EGERE
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Credential |
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Telephone | 763-537-6651
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 353271
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 353271
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License Number State | MN
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