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General NPI Number Information
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NPI Number | 1104500925
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Entity Type | Organization
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Legal Business Name | GREAT LAKES SPORT AND SPINE
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Dates
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Enumeration Date | 06/12/2023
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Last Update Date | 06/12/2023
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Provider Practice Location Address
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Address Line | 34940 RIDGE RD STE B
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City | WILLOUGHBY
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State | OH
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Zip | 44094-4197
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Country | US
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Telephone | 440-503-6683
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Fax |
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Provider Business Mailing Address
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Address Line | 34940 RIDGE RD STE B
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City | WILLOUGHBY
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State | OH
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Zip | 44094-4197
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Country | US
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Telephone | 440-503-6683
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW PAUL MARTIN
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Credential | DC
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Telephone | 440-503-6683
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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