Provider Demographics
NPI:1326164773
Name:GREAT LAKES CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:GREAT LAKES CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:DETLEFSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-420-4635
Mailing Address - Street 1:13601 80TH CIR N
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8999
Mailing Address - Country:US
Mailing Address - Phone:763-420-4635
Mailing Address - Fax:763-390-1381
Practice Address - Street 1:13601 80TH CIR N
Practice Address - Street 2:SUITE 210
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8999
Practice Address - Country:US
Practice Address - Phone:763-420-4635
Practice Address - Fax:763-390-1381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4448111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty