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Organization
GREAT LAKES SURGERY CENTER LLC
Active
Organization
GREAT LAKES SURGERY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LISA K THIERY (MANAGER)
(262) 657-3668
Entity
Organization
Contact information
Practice address
6123 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2927
(262) 657-3668
Mailing address
PO BOX 580772, PLEASANT PRAIRIE, WI 53158-8101
(262) 657-3668
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
PENDING
WI
Other
Enumeration date
06/02/2008
Last updated
03/23/2011
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