1265521447 NPI number — BACK TO HEALTH CHIROPRACTIC CLINIC, PA

Table of content: (NPI 1477830073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265521447 NPI number — BACK TO HEALTH CHIROPRACTIC CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK TO HEALTH CHIROPRACTIC CLINIC, PA
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:
1265521447
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:
5231 E. FRONTAGE HWY 52 RD NW
Provider Second Line Business Mailing Address:
SUITE 201 &202
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55901-4156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-280-6186
Provider Business Mailing Address Fax Number:
507-280-7682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5231 E. FRONTAGE HWY 52 RD NW
Provider Second Line Business Practice Location Address:
SUITE 201 &202
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55901-4156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-280-6186
Provider Business Practice Location Address Fax Number:
507-280-7682
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARQUARDT
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
507-280-6186

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2554 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 171100000X , with the licence number: 208 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 2C972MA . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com