Provider Demographics
NPI:1639513237
Name:BACK 4 LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:BACK 4 LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:267-614-0984
Mailing Address - Street 1:44 2ND STREET PIKE STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3830
Mailing Address - Country:US
Mailing Address - Phone:215-396-2225
Mailing Address - Fax:215-396-2227
Practice Address - Street 1:44 2ND STREET PIKE STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3830
Practice Address - Country:US
Practice Address - Phone:215-396-2225
Practice Address - Fax:215-396-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty