Provider Demographics
NPI:1598983173
Name:BACK DOCTORS LTD
Entity Type:Organization
Organization Name:BACK DOCTORS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-234-1455
Mailing Address - Street 1:PO BOX 24101
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-9101
Mailing Address - Country:US
Mailing Address - Phone:618-234-1455
Mailing Address - Fax:618-277-3475
Practice Address - Street 1:5003-2 NORIH ILLINOIS STREET
Practice Address - Street 2:
Practice Address - City:FAIRIVEW
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-234-1455
Practice Address - Fax:618-277-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-21
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-8683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL535130Medicare ID - Type Unspecified
ILU74143Medicare UPIN