Provider Demographics
NPI:1700947041
Name:GREGG CHIROPRACTIC LIFE CENTER NORTH P.C.
Entity Type:Organization
Organization Name:GREGG CHIROPRACTIC LIFE CENTER NORTH 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:248-391-1600
Mailing Address - Street 1:1079 S BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1045
Mailing Address - Country:US
Mailing Address - Phone:248-391-1600
Mailing Address - Fax:248-391-1624
Practice Address - Street 1:1079 S BALDWIN RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1045
Practice Address - Country:US
Practice Address - Phone:248-391-1600
Practice Address - Fax:248-391-1624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4935415Medicaid
MI4935415Medicaid