Provider Demographics
NPI:1548706534
Name:GREAT LAKES PAIN AND INJURY CENTER
Entity type:Organization
Organization Name:GREAT LAKES PAIN AND INJURY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-809-2094
Mailing Address - Street 1:15565 NORTHLAND DR.
Mailing Address - Street 2:SUITE 103 W
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-809-2094
Mailing Address - Fax:
Practice Address - Street 1:15565 NORTHLAND DR.
Practice Address - Street 2:SUITE 103 W
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-809-2094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013218261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy