Provider Demographics
NPI:1821686460
Name:THE BACK SHAK LLC
Entity Type:Organization
Organization Name:THE BACK SHAK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-267-0560
Mailing Address - Street 1:777 DRAGONFLY DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5263
Mailing Address - Country:US
Mailing Address - Phone:843-267-0560
Mailing Address - Fax:
Practice Address - Street 1:223 FRESH DR UNIT B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4462
Practice Address - Country:US
Practice Address - Phone:843-903-5772
Practice Address - Fax:843-492-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty