Provider Demographics
NPI:1306030754
Name:BACK TO BASICS CHIROPRACTIC HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:BACK TO BASICS CHIROPRACTIC HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:NOELLE
Authorized Official - Last Name:MANTEY-VANLOOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-475-4960
Mailing Address - Street 1:1318 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4725
Mailing Address - Country:US
Mailing Address - Phone:847-475-4960
Mailing Address - Fax:847-475-4966
Practice Address - Street 1:1318 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4725
Practice Address - Country:US
Practice Address - Phone:847-475-4960
Practice Address - Fax:847-475-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILVO3593Medicare UPIN
ILK14323Medicare PIN