Provider Demographics
NPI:1548432644
Name:A BACK & NECK PAIN CENTER INC
Entity Type:Organization
Organization Name:A BACK & NECK PAIN CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:RADEZKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-924-0880
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-0520
Mailing Address - Country:US
Mailing Address - Phone:509-924-0880
Mailing Address - Fax:509-924-0997
Practice Address - Street 1:9803 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-3645
Practice Address - Country:US
Practice Address - Phone:509-924-0880
Practice Address - Fax:509-924-0997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003116111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB32844Medicare PIN