Provider Demographics
NPI:1255801353
Name:GREATLAKES INJURY CENTER
Entity type:Organization
Organization Name:GREATLAKES INJURY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:CLOSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-454-1390
Mailing Address - Street 1:7217 EXCELSIOR RD STE 105
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8657
Mailing Address - Country:US
Mailing Address - Phone:218-454-1390
Mailing Address - Fax:218-454-1391
Practice Address - Street 1:7217 EXCELSIOR RD STE 105
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8657
Practice Address - Country:US
Practice Address - Phone:218-330-7873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1447644257OtherNPI