Provider Demographics
NPI:1508116088
Name:GREAT LAKES CHIROPRACTIC HEALTH
Entity Type:Organization
Organization Name:GREAT LAKES CHIROPRACTIC HEALTH
Other - Org Name:GREAT LAKES HEALTH & WELLNESS OF GRAND HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:D
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, DC
Authorized Official - Phone:616-842-9411
Mailing Address - Street 1:15 S. SEVENTH ST.
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417
Mailing Address - Country:US
Mailing Address - Phone:616-842-9411
Mailing Address - Fax:616-842-9058
Practice Address - Street 1:15 S. SEVENTH ST.
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-842-9411
Practice Address - Fax:616-842-9058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty