Provider Demographics
NPI:1679802532
Name:BACK TO THE BASICS
Entity Type:Organization
Organization Name:BACK TO THE BASICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MARTINSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-213-1544
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:MEADOW GROVE
Mailing Address - State:NE
Mailing Address - Zip Code:68752-0101
Mailing Address - Country:US
Mailing Address - Phone:402-213-1544
Mailing Address - Fax:402-331-4142
Practice Address - Street 1:9761 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-3272
Practice Address - Country:US
Practice Address - Phone:402-213-1544
Practice Address - Fax:402-331-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1560261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care