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General NPI Number Information
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NPI Number | 1740401017
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Entity Type | Organization
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Legal Business Name | GREEN LAKE MEDICAL SUPPLY, INC
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 93 KERCHEVAL AVE
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City | GROSSE POINTE FARMS
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State | MI
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Zip | 48236-3600
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Country | US
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Telephone | 313-882-3900
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Fax | 313-882-3947
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Provider Business Mailing Address
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Address Line | 18530 MACK AVE STE 411
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City | GROSSE POINTE FARMS
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State | MI
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Zip | 48236-3254
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Country | US
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Telephone | 313-882-3900
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Fax | 313-882-3947
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ROBERT LEE MOORHEAD
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Credential |
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Telephone | 313-882-3900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State | MI
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