Provider Demographics
NPI: | 1366688640 |
---|---|
Name: | GREAT LAKES PHYSICAL THERAPIES |
Entity Type: | Organization |
Organization Name: | GREAT LAKES PHYSICAL THERAPIES |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/PHYSICAL THERAPIST |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | JEFF |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | EATON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PT |
Authorized Official - Phone: | 231-744-0077 |
Mailing Address - Street 1: | 2045 HOLTON RD |
Mailing Address - Street 2: | |
Mailing Address - City: | NORTH MUSKEGON |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49445-1535 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 231-744-0077 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2045 HOLTON RD |
Practice Address - Street 2: | |
Practice Address - City: | NORTH MUSKEGON |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49445-1535 |
Practice Address - Country: | US |
Practice Address - Phone: | 231-744-0077 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-12-17 |
Last Update Date: | 2008-12-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 5501011276 | 261QP2000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |