=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548663610
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT LAKES ACCIDENT SERVICE LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2014
-----------------------------------------------------
Last Update Date | 10/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 GRISWOLD ST STE 1626
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48226-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-304-1040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22200 W 11 MILE RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48037-7136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-304-1040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MYLES ANTHONY-ISAAC FREDERICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-452-6788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 05674V
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------