Provider Demographics
NPI:1790490092
Name:BACK TO CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BACK TO CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LEER
Authorized Official - Suffix:
Authorized Official - Credentials:DC, BS
Authorized Official - Phone:260-341-4457
Mailing Address - Street 1:10913 BALDHAM PASS
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8764
Mailing Address - Country:US
Mailing Address - Phone:260-341-4457
Mailing Address - Fax:
Practice Address - Street 1:208 E WHITLEY ST
Practice Address - Street 2:
Practice Address - City:CHURUBUSCO
Practice Address - State:IN
Practice Address - Zip Code:46723-1506
Practice Address - Country:US
Practice Address - Phone:260-341-4457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty