Provider Demographics
NPI:1528486909
Name:MAPLE LAKE CHIROPRACTIC
Entity type:Organization
Organization Name:MAPLE LAKE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-876-7814
Mailing Address - Street 1:109 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1415
Mailing Address - Country:US
Mailing Address - Phone:269-876-7814
Mailing Address - Fax:
Practice Address - Street 1:109 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1415
Practice Address - Country:US
Practice Address - Phone:269-876-7814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty