# GREAT LAKES SURGERY LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1629518006
- **Authorized official:** JOHN L BOSTANCHE DPM (DIRECTOR)
- **Authorized official phone:** (262) 657-0224

## Contact information

- **Practice address:** 6123 GREEN BAY RD STE 101, KENOSHA, WI 53142-2927
- **Practice address phone:** (262) 657-0224
- **Mailing address:** 6123 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2927
- **Mailing address phone:** (262) 657-0224

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 03/03/2017
- **Last updated:** 03/03/2017