Provider Demographics
NPI:1437793932
Name:BACK AND NECK PAIN CENTER LLC
Entity Type:Organization
Organization Name:BACK AND NECK PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAPHET
Authorized Official - Middle Name:DIVAD
Authorized Official - Last Name:LEGRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:276-632-3334
Mailing Address - Street 1:1141 MEMORIAL BLVD N
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2429
Mailing Address - Country:US
Mailing Address - Phone:276-632-3334
Mailing Address - Fax:276-632-1882
Practice Address - Street 1:1141 MEMORIAL BLVD N
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2429
Practice Address - Country:US
Practice Address - Phone:276-632-3334
Practice Address - Fax:276-632-1882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-29
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty