Provider Demographics
NPI:1053835736
Name:GREAT LAKES ADULT DAY SERVICES, LLC
Entity type:Organization
Organization Name:GREAT LAKES ADULT DAY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENYATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGETTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:313-530-1161
Mailing Address - Street 1:19194 AUGUSTA CT
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19194 AUGUSTA CT
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4016
Practice Address - Country:US
Practice Address - Phone:313-530-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WC1500X, 163WC2100X, 163WG0600X, 163WN1003X, 163WP0000X, 251E00000X, 251J00000X, 252Y00000X, 372500000X, 376K00000X, 385H00000X
MI4704275716163WH1000X
WI11091605163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty
No163WC2100XNursing Service ProvidersRegistered NurseContinence CareGroup - Multi-Specialty
No163WG0600XNursing Service ProvidersRegistered NurseGerontologyGroup - Multi-Specialty
No163WH1000XNursing Service ProvidersRegistered NurseHospiceGroup - Multi-Specialty
No163WN1003XNursing Service ProvidersRegistered NurseNutrition SupportGroup - Multi-Specialty
No163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8278228Medicaid