| Organization Name: | GREEN LAKE MEDICAL SUPPLY, INC |
| NPI Number: | 1740401017 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ROBERT LEE MOORHEAD (PRESIDENT) |
| Mailing Address: | 93 Kercheval Ave Grosse Pointe Farms |
| State: | MI US |
| Postal Code: | 482363600 |
| Phone Number: | 3138823900 |
| Fax Number: | 3138823947 |
| NPI Enumeration Date: | 05/02/2007 |
| NPI Last Update Date: | 04/20/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | ========= |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |