MEDICARE: GREAT LAKES HEALTHCARE, 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	251E00000X	Home Health Agency		IL

General Provider Information

NPI Number	:	1902964802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES HEALTHCARE, LLC.

Provider Business Mailing Address
First Line	:	900 N KINGSBURY ST
Second Line	:	SUITE 1055
City	:	CHICAGO
State	:	IL
Zip	:	60610-7432
Country	:	US
Telephone Number	:	312-222-0646
Fax Number	:	312-222-0647

Provider Business Practice Location Address
First Line	:	900 N KINGSBURY ST
Second Line	:	SUITE 1055
City	:	CHICAGO
State	:	IL
Zip	:	60610-7432
Country	:	US
Telephone Number	:	312-222-0646
Fax Number	:	312-222-0647

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. GEORGE TONG
Credential	:
Telephone Number	:	312-832-1844

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	08/22/2020

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