Provider Demographics
NPI:1992865703
Name:GREGG CHIROPRACTIC LIFE CENTER P.C.
Entity Type:Organization
Organization Name:GREGG CHIROPRACTIC LIFE CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-525-8422
Mailing Address - Street 1:1647 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-3086
Mailing Address - Country:US
Mailing Address - Phone:734-525-8422
Mailing Address - Fax:734-525-5421
Practice Address - Street 1:1647 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-3086
Practice Address - Country:US
Practice Address - Phone:734-525-8422
Practice Address - Fax:734-525-5421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1008872Medicaid
MI6693110001OtherDMEPOS
MI1008872Medicaid