Provider Demographics
NPI:1538122437
Name:BACK CARE OF SPIRIT LAKE, INC.
Entity Type:Organization
Organization Name:BACK CARE OF SPIRIT LAKE, INC.
Other - Org Name:BACK CARE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-336-5311
Mailing Address - Street 1:2309 23RD ST.
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-0342
Mailing Address - Country:US
Mailing Address - Phone:712-336-5320
Mailing Address - Fax:712-336-0020
Practice Address - Street 1:2309 23RD ST.
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-0342
Practice Address - Country:US
Practice Address - Phone:712-336-5320
Practice Address - Fax:712-336-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0496174Medicaid
MN4568080001Medicare NSC
IA4568080002Medicare NSC
IA48421Medicare PIN