Provider Demographics
NPI:1245580059
Name:GULL LAKE CHIROPRACTIC INC
Entity Type:Organization
Organization Name:GULL LAKE CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:OSTROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-629-5090
Mailing Address - Street 1:9363 E D AVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9497
Mailing Address - Country:US
Mailing Address - Phone:269-629-5090
Mailing Address - Fax:269-629-5085
Practice Address - Street 1:9363 E D AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-9497
Practice Address - Country:US
Practice Address - Phone:269-629-5090
Practice Address - Fax:269-629-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI144729785Medicaid
0C95019Medicare PIN