Provider Demographics
NPI:1326123084
Name:BACK TO BASICS S.C.
Entity Type:Organization
Organization Name:BACK TO BASICS S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MILLAN
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:920-465-1431
Mailing Address - Street 1:PO BOX 8844
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8844
Mailing Address - Country:US
Mailing Address - Phone:920-465-1431
Mailing Address - Fax:920-468-0405
Practice Address - Street 1:1792 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3251
Practice Address - Country:US
Practice Address - Phone:920-465-1431
Practice Address - Fax:920-468-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV01035Medicare UPIN