Provider Demographics
NPI:1285934638
Name:GREAT LAKES HEALTH, INC
Entity type:Organization
Organization Name:GREAT LAKES HEALTH, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:F
Authorized Official - Last Name:HENDRIKZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-579-9439
Mailing Address - Street 1:9070 RESEARCH BLVD
Mailing Address - Street 2:STE. 105
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-7004
Mailing Address - Country:US
Mailing Address - Phone:512-454-2578
Mailing Address - Fax:512-374-9911
Practice Address - Street 1:9070 RESEARCH BLVD
Practice Address - Street 2:STE. 105
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-7004
Practice Address - Country:US
Practice Address - Phone:512-454-2578
Practice Address - Fax:512-374-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center