Provider Demographics
NPI:1639779473
Name:BACK HOME CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BACK HOME CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-844-4421
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:FAIR GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65648-0434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 W OLD MILL RD
Practice Address - Street 2:
Practice Address - City:FAIR GROVE
Practice Address - State:MO
Practice Address - Zip Code:65648-8646
Practice Address - Country:US
Practice Address - Phone:417-567-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty