Provider Demographics
NPI:1326021692
Name:BACKSTROM, DONALD B (MS, DC)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:B
Last Name:BACKSTROM
Suffix:
Gender:M
Credentials:MS, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 CRESCENT BLVD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4540
Mailing Address - Country:US
Mailing Address - Phone:630-790-2440
Mailing Address - Fax:630-790-4202
Practice Address - Street 1:496 CRESCENT BLVD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4540
Practice Address - Country:US
Practice Address - Phone:630-790-2440
Practice Address - Fax:630-790-4202
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005628111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILEIN36-3593822OtherEMPLOYEE TAX ID NUMBER
ILK50420Medicare PIN
ILT39237Medicare UPIN