Healthcare Provider Details

I. General information

NPI: 1104500925
Provider Name (Legal Business Name): GREAT LAKES SPORT AND SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34940 RIDGE RD STE B
WILLOUGHBY OH
44094-4197
US

IV. Provider business mailing address

34940 RIDGE RD STE B
WILLOUGHBY OH
44094-4197
US

V. Phone/Fax

Practice location:
  • Phone: 440-503-6683
  • Fax:
Mailing address:
  • Phone: 440-503-6683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW PAUL MARTIN
Title or Position: OWNER
Credential: DC
Phone: 440-503-6683