Provider Demographics
NPI:1720564149
Name:GREAT LAKES CHIROPRACTIC & MOVEMENT PLLC
Entity Type:Organization
Organization Name:GREAT LAKES CHIROPRACTIC & MOVEMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MOREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-234-5431
Mailing Address - Street 1:4215 MILLER RD # A8
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1299
Mailing Address - Country:US
Mailing Address - Phone:810-234-5431
Mailing Address - Fax:
Practice Address - Street 1:4215 MILLER RD # A8
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1299
Practice Address - Country:US
Practice Address - Phone:810-234-5431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009577111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301009577OtherSTATE LICENSE