# GREAT LAKES PHYSICAL MEDICINE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1356973267
- **Authorized official:** ERIC D WOLK DC (OWNER)
- **Authorized official phone:** (570) 575-5414

## Contact information

- **Practice address:** 25200 CHAGRIN BLVD STE 103, BEACHWOOD, OH 44122-5681
- **Practice address phone:** (570) 575-5414
- **Mailing address:** 25200 CHAGRIN BLVD STE 103, BEACHWOOD, OH 44122-5681
- **Mailing address phone:** (570) 575-5414

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 111N00000X | Chiropractor | — | — | Yes |
| 261QP2000X | Physical Therapy Clinic/Center | — | — | — |

## Other

- **Enumeration date:** 02/08/2020
- **Last updated:** 02/08/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0281891 | — | OH |