Provider Demographics
NPI:1528153103
Name:GRGICAK, JOHN (DC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:GRGICAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:E
Other - Last Name:GRGICAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:716 WEST 11 MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2411
Mailing Address - Country:US
Mailing Address - Phone:248-544-9009
Mailing Address - Fax:248-544-9002
Practice Address - Street 1:716 WEST 11 MILE ROAD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2411
Practice Address - Country:US
Practice Address - Phone:248-544-9009
Practice Address - Fax:248-544-9002
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJG008248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU92391Medicare UPIN
MI000000011114Medicare UPIN
MI0P17440Medicare ID - Type UnspecifiedMEDICARE