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General NPI Number Information
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NPI Number | 1811975717
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Entity Type | Organization
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Legal Business Name | GREAT LAKES FAMILY CHIROPRACTIC, INC.
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Dates
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Enumeration Date | 01/03/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3138 BROADMOOR AVE SE
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City | KENTWOOD
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State | MI
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Zip | 49512-1845
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Country | US
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Telephone | 616-241-4040
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Fax | 616-475-6953
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Provider Business Mailing Address
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Address Line | 3138 BROADMOOR AVE SE
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City | KENTWOOD
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State | MI
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Zip | 49512-1845
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Country | US
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Telephone | 616-241-4040
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Fax | 616-475-6953
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Authorized Official
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Title or Position | DR. OWNER
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Name | DR. DOUGLAS GENE MCKENZIE
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Credential | D.C.
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Telephone | 616-241-4040
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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 | 2301008451
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License Number State | MI
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