MEDICARE: GREAT LAKES VISION REHABILITATION PLLC

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	152WV0400X	Vision Therapy Optometrist

General Provider Information

NPI Number	:	1962118760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES VISION REHABILITATION PLLC

Provider Business Mailing Address
First Line	:	48189 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48317-3268
Country	:	US
Telephone Number	:	586-731-9725
Fax Number	:

Provider Business Practice Location Address
First Line	:	48189 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48317-3268
Country	:	US
Telephone Number	:	586-731-9725
Fax Number	:	586-488-0006

Authorized Official
Title or Position	:	OWNER
Name	:	DR. AARON NICHOLS
Credential	:	OD
Telephone Number	:	734-578-8598

Provider Enumeration Date	:	01/25/2023
Last Update Date	:	01/31/2023

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