Provider Demographics
NPI:1972326163
Name:GREAT LAKES ORTHOTICS AND PROSTHETICS
Entity type:Organization
Organization Name:GREAT LAKES ORTHOTICS AND PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:TYNESHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCFARLAND-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-594-2801
Mailing Address - Street 1:3124 ELK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8630
Mailing Address - Country:US
Mailing Address - Phone:601-594-2801
Mailing Address - Fax:
Practice Address - Street 1:2351 STONEBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5407
Practice Address - Country:US
Practice Address - Phone:601-594-2801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies