Provider Demographics
NPI:1902045685
Name:GREAT LAKES CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:GREAT LAKES CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLOODWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-939-1003
Mailing Address - Street 1:4105 METROPOLITAN PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-7503
Mailing Address - Country:US
Mailing Address - Phone:586-939-1003
Mailing Address - Fax:586-939-3862
Practice Address - Street 1:4105 METROPOLITAN PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-7503
Practice Address - Country:US
Practice Address - Phone:586-939-1003
Practice Address - Fax:586-939-3862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007508111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M76000Medicare UPIN