# GREAT LAKES SURGERY CENTER LLC

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

## Provider details

- **NPI number:** 1700045168
- **Authorized official:** MRS. LISA K THIERY (MANAGER)
- **Authorized official phone:** (262) 657-3668

## Contact information

- **Practice address:** 6123 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2927
- **Practice address phone:** (262) 657-3668
- **Mailing address:** PO BOX 580772, PLEASANT PRAIRIE, WI 53158-8101
- **Mailing address phone:** (262) 657-3668

## Taxonomy

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

## Other

- **Enumeration date:** 06/02/2008
- **Last updated:** 03/23/2011