Provider Demographics
NPI:1508872334
Name:BACK IN ACTION WELLNESS CENTER
Entity Type:Organization
Organization Name:BACK IN ACTION WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VARSOVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOLIVA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-385-9001
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-0554
Mailing Address - Country:US
Mailing Address - Phone:708-385-9001
Mailing Address - Fax:708-385-2114
Practice Address - Street 1:12757 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2155
Practice Address - Country:US
Practice Address - Phone:708-385-9001
Practice Address - Fax:708-385-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU88474OtherDOCTOR UPIN #
IL02227830OtherBC/BS PROVIDER #
IL02227830OtherBC/BS PROVIDER #