Provider Demographics
NPI:1750493086
Name:GREAT LAKES CHIROPRACTIC OF MICHIGAN PLLC
Entity Type:Organization
Organization Name:GREAT LAKES CHIROPRACTIC OF MICHIGAN PLLC
Other - Org Name:GREAT LAKES CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-946-7800
Mailing Address - Street 1:2000 CHARTWELL DR
Mailing Address - Street 2:STE 2
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-9348
Mailing Address - Country:US
Mailing Address - Phone:231-946-7800
Mailing Address - Fax:231-946-1800
Practice Address - Street 1:2000 CHARTWELL DR
Practice Address - Street 2:STE 2
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-9348
Practice Address - Country:US
Practice Address - Phone:231-946-7800
Practice Address - Fax:231-946-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950B811590OtherBC/BS ID NUMBER
MI0P36470Medicare PIN