Provider Demographics
NPI:1609076421
Name:GRAND BLANC SPINE CENTER
Entity Type:Organization
Organization Name:GRAND BLANC SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MORNINGSTAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-694-3576
Mailing Address - Street 1:10683 S SAGINAW ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8127
Mailing Address - Country:US
Mailing Address - Phone:810-694-3576
Mailing Address - Fax:810-694-9544
Practice Address - Street 1:10683 S SAGINAW ST
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8127
Practice Address - Country:US
Practice Address - Phone:810-694-3576
Practice Address - Fax:810-694-9544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2014-12-10
Deactivation Date:2012-11-27
Deactivation Code:
Reactivation Date:2014-12-10
Provider Licenses
StateLicense IDTaxonomies
MIMM008587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4446888Medicaid