Provider Demographics
NPI:1710768494
Name:GREAT LAKES SPORTS & SPINE LLC
Entity Type:Organization
Organization Name:GREAT LAKES SPORTS & SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-503-6683
Mailing Address - Street 1:502 WINDHAM CT
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-4214
Mailing Address - Country:US
Mailing Address - Phone:440-503-6683
Mailing Address - Fax:
Practice Address - Street 1:34940 RIDGE RD STE B
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4197
Practice Address - Country:US
Practice Address - Phone:440-527-8030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty