Provider Demographics
NPI:1417301847
Name:BACK TO LIFE CHIROPRACTIC L.L.C
Entity Type:Organization
Organization Name:BACK TO LIFE CHIROPRACTIC L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATOR/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:GANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-728-6649
Mailing Address - Street 1:761 INDIAN BOUNDARY RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1586
Mailing Address - Country:US
Mailing Address - Phone:219-728-6649
Mailing Address - Fax:888-741-5926
Practice Address - Street 1:761 INDIAN BOUNDARY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-1586
Practice Address - Country:US
Practice Address - Phone:219-728-6649
Practice Address - Fax:888-741-5926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002566A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201358400 AMedicaid
IN201358400 AMedicaid