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General NPI Number Information
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NPI Number | 1285929547
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Entity Type | Organization
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Legal Business Name | GREAT LAKES SPINE & REHAB CLINIC LLC
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Dates
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Enumeration Date | 06/15/2011
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Last Update Date | 12/29/2011
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Provider Practice Location Address
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Address Line | 14500 KING RD
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City | RIVERVIEW
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State | MI
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Zip | 48193-7957
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Country | US
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Telephone | 734-560-7300
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Fax | 734-250-7454
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Provider Business Mailing Address
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Address Line | 14500 KING RD
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City | RIVERVIEW
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State | MI
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Zip | 48193-7957
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Country | US
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Telephone | 734-560-7300
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Fax | 734-250-7454
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | RICHARD J STANLEY
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Credential | DC
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Telephone | 734-560-7300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | RS008086
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License Number State | MI
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