MEDICARE: GREAT LAKES MEDICAL SERVICES 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1922248863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES MEDICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	25660 DIXIE HWY
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-2167
Country	:	US
Telephone Number	:	419-872-5343
Fax Number	:	419-872-7464

Provider Business Practice Location Address
First Line	:	25660 DIXIE HWY
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-2167
Country	:	US
Telephone Number	:	419-872-5343
Fax Number	:	419-872-7464

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EVAN KYLE PRUETER
Credential	:
Telephone Number	:	419-872-5343

Provider Enumeration Date	:	03/05/2009
Last Update Date	:	03/05/2009

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