Provider Demographics
NPI:1467745034
Name:BACK PAIN RELIEF CLINIC, INC
Entity Type:Organization
Organization Name:BACK PAIN RELIEF CLINIC, INC
Other - Org Name:BACK PAIN RELIEF CLINIC DRESDEN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BONE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:731-364-2202
Mailing Address - Street 1:138 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-1467
Mailing Address - Country:US
Mailing Address - Phone:731-364-2202
Mailing Address - Fax:
Practice Address - Street 1:138 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:TN
Practice Address - Zip Code:38225-1467
Practice Address - Country:US
Practice Address - Phone:731-364-2202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6274140001Medicare NSC
TN3723436Medicare PIN