Provider Demographics
NPI:1376725911
Name:BACK 2 LIFE CHIROPRACTIC, PSC
Entity Type:Organization
Organization Name:BACK 2 LIFE CHIROPRACTIC, PSC
Other - Org Name:BOND CHIROPRACTIC, PSC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:502-867-0089
Mailing Address - Street 1:104 LAWSON DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8998
Mailing Address - Country:US
Mailing Address - Phone:502-867-0089
Mailing Address - Fax:502-867-0180
Practice Address - Street 1:104 LAWSON DR
Practice Address - Street 2:SUITE 107
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8998
Practice Address - Country:US
Practice Address - Phone:502-867-0089
Practice Address - Fax:502-867-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000227300OtherBLUECROSS BLUESHIELD
KY111N0000XOtherTAXONOMY
KY645717OtherUHC
KY8500227Medicaid
KY7197394OtherAETNA
KY1196909OtherCHA
KY7187OtherMEDICARE GROUP
KY8500227Medicaid