# GREAT LAKES SPORTS & SPINE LLC

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

## Provider details

- **NPI number:** 1710768494
- **Authorized official:** DR. MATTHEW PAUL MARTIN DC (OWNER/CHIROPRACTIC PHYSICIAN)
- **Authorized official phone:** (440) 503-6683

## Contact information

- **Practice address:** 34940 RIDGE RD STE B, WILLOUGHBY, OH 44094-4197
- **Practice address phone:** (440) 527-8030
- **Mailing address:** 502 WINDHAM CT, BROADVIEW HEIGHTS, OH 44147-4214
- **Mailing address phone:** (440) 503-6683

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 111N00000X | Chiropractor | — | — | Yes |

## Other

- **Enumeration date:** 10/10/2023
- **Last updated:** 10/10/2023