Provider Demographics
NPI:1538398748
Name:GREAT LAKES SCOLIOSIS CENTER, P.C.
Entity type:Organization
Organization Name:GREAT LAKES SCOLIOSIS CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ALONZO
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:586-365-8988
Mailing Address - Street 1:51210 ROMEO PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4129
Mailing Address - Country:US
Mailing Address - Phone:586-365-8988
Mailing Address - Fax:
Practice Address - Street 1:51210 ROMEO PLANK RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4129
Practice Address - Country:US
Practice Address - Phone:586-365-8988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty