Provider Demographics
NPI:1134289952
Name:GREGG CHIROPRACTIC LIFE CENTER WEST P.C.
Entity Type:Organization
Organization Name:GREGG CHIROPRACTIC LIFE CENTER WEST P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-261-7590
Mailing Address - Street 1:33779 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-2850
Mailing Address - Country:US
Mailing Address - Phone:734-261-7590
Mailing Address - Fax:734-261-3799
Practice Address - Street 1:33779 5 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2850
Practice Address - Country:US
Practice Address - Phone:734-261-7590
Practice Address - Fax:734-261-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4714512Medicaid
MIOM19570Medicare ID - Type Unspecified