MEDICARE: GREEN LAKE OPCO, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881074961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN LAKE OPCO, LLC

Provider Business Mailing Address
First Line	:	3755 CHASE AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-4008
Country	:	US
Telephone Number	:	847-440-2660
Fax Number	:

Provider Business Practice Location Address
First Line	:	6470 ALDEN DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-2006
Country	:	US
Telephone Number	:	248-363-4121
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MARCELLA GRAF
Credential	:
Telephone Number	:	224-470-2044

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	11/04/2025

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Directions to “GREEN LAKE OPCO, LLC ” Practice Location

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