Provider Demographics
NPI:1003051343
Name:THE BACK SHACK LLC
Entity Type:Organization
Organization Name:THE BACK SHACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FESCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-775-9642
Mailing Address - Street 1:6740 JAMES B RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2235
Mailing Address - Country:US
Mailing Address - Phone:404-775-9642
Mailing Address - Fax:
Practice Address - Street 1:6740 JAMES B RIVERS DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2235
Practice Address - Country:US
Practice Address - Phone:404-775-9642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty