1013042647 NPI number — BACK TO HEALTH CHIROPRACTIC OF RISING SUN, PC

Table of content: (NPI 1013042647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013042647 NPI number — BACK TO HEALTH CHIROPRACTIC OF RISING SUN, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK TO HEALTH CHIROPRACTIC OF RISING SUN, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013042647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 66
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VEVAY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47043-0066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-525-6546
Provider Business Mailing Address Fax Number:
812-438-9222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 S WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RISING SUN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47040-1172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-438-9222
Provider Business Practice Location Address Fax Number:
812-438-9222
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TROY
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
812-525-6546

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  08001849A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00045015 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000298895 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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