Provider Demographics
NPI:1376676957
Name:BACK TO WELLNESS CENTER
Entity Type:Organization
Organization Name:BACK TO WELLNESS CENTER
Other - Org Name:INJURY CARE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEAUFORD
Authorized Official - Middle Name:T
Authorized Official - Last Name:ERWIN
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:817-732-3344
Mailing Address - Street 1:3930 W VICKERY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5626
Mailing Address - Country:US
Mailing Address - Phone:817-732-3344
Mailing Address - Fax:817-732-3353
Practice Address - Street 1:3930 W VICKERY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5626
Practice Address - Country:US
Practice Address - Phone:817-732-3344
Practice Address - Fax:817-732-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC8345111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0053KNOtherBCBS GROUP #