Provider Demographics
NPI:1669498036
Name:BACK TO MEDICINE, INC
Entity Type:Organization
Organization Name:BACK TO MEDICINE, INC
Other - Org Name:DR DWAIN W. RICKERTSEN, M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:RICKERTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-751-1701
Mailing Address - Street 1:1215 PLUMAS ST
Mailing Address - Street 2:STE 101
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-3455
Mailing Address - Country:US
Mailing Address - Phone:530-751-1701
Mailing Address - Fax:530-751-1705
Practice Address - Street 1:1215 PLUMAS ST
Practice Address - Street 2:STE 101
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-3455
Practice Address - Country:US
Practice Address - Phone:530-751-1701
Practice Address - Fax:530-751-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA450730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E90666Medicare UPIN
CA00A450730Medicare ID - Type Unspecified