MEDICARE: GREAT LAKES SCOLIOSIS CENTER, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301008704	MI

General Provider Information

NPI Number	:	1538398748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES SCOLIOSIS CENTER, P.C.

Provider Business Mailing Address
First Line	:	51210 ROMEO PLANK RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4129
Country	:	US
Telephone Number	:	586-365-8988
Fax Number	:

Provider Business Practice Location Address
First Line	:	51210 ROMEO PLANK RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4129
Country	:	US
Telephone Number	:	586-365-8988
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACK ALONZO MOSES JR.
Credential	:	D.C.
Telephone Number	:	586-365-8988

Provider Enumeration Date	:	07/09/2009
Last Update Date	:	09/09/2011

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51210 ROMEO PLANK RD
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