Organization
GREAT LAKES HEALTHCARE, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH EUGENE DAMBACHER D.O. (OWNER)
(810) 378-4900
Entity
Organization
Contact information
Practice address
251 E PECK RD, PECK, MI 48466-9589
(810) 378-4900
(810) 378-4905
Mailing address
PO BOX 129, YALE, MI 48097-0129
(810) 378-4900
(810) 378-4905
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5101008768
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
08-0G61059-0
BLUE CROSS BLUE SHIELD OF MICHIGAN
MI
05
—
114469926
—
MI
01
—
5670042
BLUE CROSS BLUE SHIELD OF MICHIGAN
MI
Enumeration date
06/18/2008
Last updated
11/10/2009
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