Provider Demographics
NPI:1003126657
Name:BACK IN ACTION HEALTH CENTER PC
Entity Type:Organization
Organization Name:BACK IN ACTION HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-688-7888
Mailing Address - Street 1:175 W 900 S
Mailing Address - Street 2:STE 6
Mailing Address - City:ST. GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5269
Mailing Address - Country:US
Mailing Address - Phone:435-688-7888
Mailing Address - Fax:435-652-1972
Practice Address - Street 1:175 W 900 S
Practice Address - Street 2:STE 6
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5269
Practice Address - Country:US
Practice Address - Phone:435-688-7888
Practice Address - Fax:435-652-1972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT352673-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT43992Medicare UPIN
UT000056341Medicare PIN