Provider Demographics
NPI:1407019698
Name:CHIROPRACTIC CARE GRAND TRAVERSE, PC
Entity Type:Organization
Organization Name:CHIROPRACTIC CARE GRAND TRAVERSE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-922-0233
Mailing Address - Street 1:620 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2272
Mailing Address - Country:US
Mailing Address - Phone:231-922-0233
Mailing Address - Fax:231-941-9832
Practice Address - Street 1:620 SECOND ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2272
Practice Address - Country:US
Practice Address - Phone:231-922-0233
Practice Address - Fax:231-941-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005511111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMZ005511OtherBLUE CROSS BLUE SHIELD
MI144355184Medicaid
MIMZ005511OtherBLUE CROSS BLUE SHIELD
MI0M77080Medicare PIN