Provider Demographics
NPI:1407024144
Name:GREAT LAKES FAMILY CHIROPRACTIC CENTER,PC
Entity Type:Organization
Organization Name:GREAT LAKES FAMILY CHIROPRACTIC CENTER,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HULSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-824-6442
Mailing Address - Street 1:1009 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16504-1843
Mailing Address - Country:US
Mailing Address - Phone:814-824-6442
Mailing Address - Fax:814-824-4007
Practice Address - Street 1:1009 E 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16504-1843
Practice Address - Country:US
Practice Address - Phone:814-824-6442
Practice Address - Fax:814-824-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005135L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1394234OtherBLUE CROSS/BLUE SHIELD