Provider Demographics
NPI:1073758033
Name:GREAT LAKES FAMILY CHIROPRACTIC PLC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY CHIROPRACTIC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-668-3709
Mailing Address - Street 1:25344 RED ARROW HWY
Mailing Address - Street 2:STE A
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9767
Mailing Address - Country:US
Mailing Address - Phone:269-668-3709
Mailing Address - Fax:269-668-3713
Practice Address - Street 1:25344 RED ARROW HWY
Practice Address - Street 2:STE A
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9767
Practice Address - Country:US
Practice Address - Phone:269-668-3709
Practice Address - Fax:269-668-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4736930Medicaid
MI0N85880Medicare PIN