Provider Demographics
NPI:1225182892
Name:BACK IN MOTION CHIROPRACTIC
Entity Type:Organization
Organization Name:BACK IN MOTION CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-504-0395
Mailing Address - Street 1:9664 63RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6200
Mailing Address - Country:US
Mailing Address - Phone:763-504-0395
Mailing Address - Fax:763-504-0397
Practice Address - Street 1:9664 63RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6200
Practice Address - Country:US
Practice Address - Phone:763-504-0395
Practice Address - Fax:763-504-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN096225200Medicaid
MN350003774Medicare ID - Type Unspecified
MN096225200Medicaid