Provider Demographics
NPI:1366627606
Name:BACK CLINIC, LLC
Entity Type:Organization
Organization Name:BACK CLINIC, LLC
Other - Org Name:BACK CLINIC OF MISSISSIPPI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-936-3515
Mailing Address - Street 1:1050 N FLOWOOD DR
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9738
Mailing Address - Country:US
Mailing Address - Phone:601-936-3515
Mailing Address - Fax:601-936-0705
Practice Address - Street 1:1050 N FLOWOOD DR
Practice Address - Street 2:SUITE A-1
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9738
Practice Address - Country:US
Practice Address - Phone:601-936-3515
Practice Address - Fax:601-936-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty