Provider Demographics
NPI:1366688640
Name:GREAT LAKES PHYSICAL THERAPIES
Entity type:Organization
Organization Name:GREAT LAKES PHYSICAL THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:A
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:231-744-0077
Mailing Address - Street 1:2045 HOLTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTH MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1535
Mailing Address - Country:US
Mailing Address - Phone:231-744-0077
Mailing Address - Fax:
Practice Address - Street 1:2045 HOLTON RD
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1535
Practice Address - Country:US
Practice Address - Phone:231-744-0077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011276261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy