Provider Demographics
NPI:1073821260
Name:BACK TO LIFE NATURAL HEALTH CENTER
Entity Type:Organization
Organization Name:BACK TO LIFE NATURAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DENIS
Authorized Official - Last Name:LEDOUX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-546-3736
Mailing Address - Street 1:2960 WINNETKA AVE N
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55427
Mailing Address - Country:US
Mailing Address - Phone:763-546-3736
Mailing Address - Fax:763-546-3807
Practice Address - Street 1:2960 WINNETKA AVE N
Practice Address - Street 2:SUITE 110
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55427
Practice Address - Country:US
Practice Address - Phone:763-546-3736
Practice Address - Fax:763-546-3807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty