Provider Demographics
NPI:1477861573
Name:BACK ESSENTIALS, INC.
Entity Type:Organization
Organization Name:BACK ESSENTIALS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC DABCO
Authorized Official - Phone:719-573-2225
Mailing Address - Street 1:3431 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-3812
Mailing Address - Country:US
Mailing Address - Phone:318-425-2225
Mailing Address - Fax:318-425-2221
Practice Address - Street 1:4742 BARNES RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-1643
Practice Address - Country:US
Practice Address - Phone:719-573-2225
Practice Address - Fax:719-573-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6242111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DH90Medicare PIN