Provider Demographics
NPI:1235173196
Name:BACK TO HEALTH CHIROPRACTIC ALLIANCE, LLC
Entity Type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC ALLIANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/D.C.
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-882-5602
Mailing Address - Street 1:621 KLAMATH AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6130
Mailing Address - Country:US
Mailing Address - Phone:541-882-5602
Mailing Address - Fax:541-882-5897
Practice Address - Street 1:621 KLAMATH AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6130
Practice Address - Country:US
Practice Address - Phone:541-882-5602
Practice Address - Fax:541-882-5897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0600001738111N00000X
OR3071111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR116691Medicare PIN