Provider Demographics
NPI:1811975717
Name:GREAT LAKES FAMILY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:GREAT LAKES FAMILY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-241-4040
Mailing Address - Street 1:3138 BROADMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1845
Mailing Address - Country:US
Mailing Address - Phone:616-241-4040
Mailing Address - Fax:616-475-6953
Practice Address - Street 1:3138 BROADMOOR AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-1845
Practice Address - Country:US
Practice Address - Phone:616-241-4040
Practice Address - Fax:616-475-6953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4754106Medicaid
MI4754106Medicaid