1285929547 NPI number — GREAT LAKES SPINE & REHAB CLINIC LLC

Table of content: (NPI 1285929547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285929547 NPI number — GREAT LAKES SPINE & REHAB CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES SPINE & REHAB CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285929547
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14500 KING RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48193-7957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-560-7300
Provider Business Mailing Address Fax Number:
734-250-7454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14500 KING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48193-7957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-560-7300
Provider Business Practice Location Address Fax Number:
734-250-7454
Provider Enumeration Date:
06/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
STANLEY
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
734-560-7300

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  RS008086 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4829904-14 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 950H217760 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com