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General NPI Number Information
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NPI Number | 1700045168
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Entity Type | Organization
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Legal Business Name | GREAT LAKES SURGERY CENTER LLC
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Dates
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Enumeration Date | 06/02/2008
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Last Update Date | 03/23/2011
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Provider Practice Location Address
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Address Line | 6123 GREEN BAY RD SUITE 100
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City | KENOSHA
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State | WI
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Zip | 53142-2927
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Country | US
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Telephone | 262-657-3668
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 580772
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City | PLEASANT PRAIRIE
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State | WI
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Zip | 53158-8101
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Country | US
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Telephone | 262-657-3668
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. LISA K THIERY
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Credential |
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Telephone | 262-657-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | PENDING
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License Number State | WI
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