Provider Demographics
NPI:1285929547
Name:GREAT LAKES SPINE & REHAB CLINIC LLC
Entity type:Organization
Organization Name:GREAT LAKES SPINE & REHAB CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-560-7300
Mailing Address - Street 1:14500 KING RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7957
Mailing Address - Country:US
Mailing Address - Phone:734-560-7300
Mailing Address - Fax:734-250-7454
Practice Address - Street 1:14500 KING RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7957
Practice Address - Country:US
Practice Address - Phone:734-560-7300
Practice Address - Fax:734-250-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRS008086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4829904-14Medicaid
MI950H217760OtherBCBSM
MI0N34030Medicare PIN
MIU80431Medicare UPIN