| Organization Name: | GREAT LAKES CHIROPRACTIC LLC |
| NPI Number: | 1326164773 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | PHILLIP J DETLEFSEN (OWNER) |
| Mailing Address: | 13601 80th Cir N Suite 210 Maple Grove |
| State: | MN US |
| Postal Code: | 553698999 |
| Phone Number: | 7634204635 |
| Fax Number: | 7633901381 |
| NPI Enumeration Date: | 03/21/2007 |
| NPI Last Update Date: | 06/24/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 4448 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |