Provider Demographics
NPI:1588808992
Name:BACK & BODY CHIROPRACTIC
Entity Type:Organization
Organization Name:BACK & BODY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-239-2936
Mailing Address - Street 1:18480 KENYON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 SILVER BELL RD STE 9
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1050
Practice Address - Country:US
Practice Address - Phone:651-452-7018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty