Provider Demographics
NPI:1265774368
Name:GREAT LAKES PHYSICAL THERAPY-NORTH MUSKEGON, LLC
Entity type:Organization
Organization Name:GREAT LAKES PHYSICAL THERAPY-NORTH MUSKEGON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT, FAFS
Authorized Official - Phone:231-744-0077
Mailing Address - Street 1:2045 HOLTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTH MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-1535
Mailing Address - Country:US
Mailing Address - Phone:231-744-0077
Mailing Address - Fax:231-744-0030
Practice Address - Street 1:2045 HOLTON RD
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1535
Practice Address - Country:US
Practice Address - Phone:231-744-0077
Practice Address - Fax:231-744-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30609OtherBCBS
MI4717630Medicaid
MI30609OtherBCBS