Provider Demographics
NPI:1114366259
Name:BACK ON TRACK CHIROPRACTIC
Entity Type:Organization
Organization Name:BACK ON TRACK CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-963-0504
Mailing Address - Street 1:2051 W. WARNER RD.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-8700
Mailing Address - Country:US
Mailing Address - Phone:480-963-0504
Mailing Address - Fax:480-963-2899
Practice Address - Street 1:2051 W WARNER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2100
Practice Address - Country:US
Practice Address - Phone:480-963-0504
Practice Address - Fax:480-963-2899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ129063Medicare PIN
AZZ64486Medicare PIN