Provider Demographics
NPI:1154511947
Name:BACK TO HEALTH COMPLEMENTARY AND ALTERNATIVE MEDICINE CENTER, LTD
Entity Type:Organization
Organization Name:BACK TO HEALTH COMPLEMENTARY AND ALTERNATIVE MEDICINE CENTER, LTD
Other - Org Name:BACK TO HEALTH CHIROPRACTIC, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIROPRACTOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-294-7792
Mailing Address - Street 1:5005 E STOP 11 RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9447
Mailing Address - Country:US
Mailing Address - Phone:317-881-8119
Mailing Address - Fax:
Practice Address - Street 1:5005 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9447
Practice Address - Country:US
Practice Address - Phone:317-881-8119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001136A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN254730Medicare PIN