Provider Demographics
NPI:1447393954
Name:BACK TO HEALTH CHIROPRACTIC INC
Entity Type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-787-6400
Mailing Address - Street 1:PO BOX 1194
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:WY
Mailing Address - Zip Code:82937-1194
Mailing Address - Country:US
Mailing Address - Phone:307-787-6400
Mailing Address - Fax:307-787-6401
Practice Address - Street 1:120 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:WY
Practice Address - Zip Code:82937-1194
Practice Address - Country:US
Practice Address - Phone:307-787-6400
Practice Address - Fax:307-787-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY611111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9678Medicare PIN