Provider Demographics
NPI:1093038010
Name:BACK TO LIFE LLC
Entity Type:Organization
Organization Name:BACK TO LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:603-525-3335
Mailing Address - Street 1:3 ELMWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:NH
Mailing Address - Zip Code:03449-5629
Mailing Address - Country:US
Mailing Address - Phone:603-525-3335
Mailing Address - Fax:866-661-5548
Practice Address - Street 1:3 ELMWOOD RD
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:NH
Practice Address - Zip Code:03449-5629
Practice Address - Country:US
Practice Address - Phone:603-525-3335
Practice Address - Fax:866-611-5548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8450809111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH08132071OtherBCBS
NH0019271OtherMEDICARE PTAN