Provider Demographics
NPI:1225482557
Name:GREAT LAKES HEALTHCARE, INC.
Entity Type:Organization
Organization Name:GREAT LAKES HEALTHCARE, INC.
Other - Org Name:CHIROSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:F
Authorized Official - Last Name:HENDRIKZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:713-425-2524
Mailing Address - Street 1:2437 BAY AREA BLVD
Mailing Address - Street 2:139
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-1519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3033 MARINA BAY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3984
Practice Address - Country:US
Practice Address - Phone:713-425-2524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-23
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11399111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty