Basic Information
| Provider Information | |||||||||
| NPI: | 1447563051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND OAKS SPINE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39915 GRAND RIVER AVE | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483752153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484695408 | ||||||||
| FaxNumber: | 2489874972 | ||||||||
| Practice Location | |||||||||
| Address1: | 39915 GRAND RIVER AVE | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483752153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484695408 | ||||||||
| FaxNumber: | 2489874972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 01/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | DENNING | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | RANDALL | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR OF CHIROPRACTIC | ||||||||
| AuthorizedOfficialTelephone: | 2484695408 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2301008370 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.