Healthcare Provider Details

I. General information

NPI: 1518734797
Provider Name (Legal Business Name): SUMMIT REGENERATIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ELIZABETH LAKE RD STE 100
WATERFORD MI
48328-3281
US

IV. Provider business mailing address

2801 ELIZABETH LAKE RD STE 100
WATERFORD MI
48328-3281
US

V. Phone/Fax

Practice location:
  • Phone: 248-683-6260
  • Fax:
Mailing address:
  • Phone: 248-683-6260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMUEL A GRAY
Title or Position: OWNER
Credential: DC
Phone: 248-683-6260