Provider Demographics
NPI:1922124528
Name:BACK INTO LIFE CHIROPRACTIC PA
Entity Type:Organization
Organization Name:BACK INTO LIFE CHIROPRACTIC PA
Other - Org Name:BACK INTO LIFE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TERNUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-712-5986
Mailing Address - Street 1:7533 SUNWOOD DR NW
Mailing Address - Street 2:STE. 212
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-4973
Mailing Address - Country:US
Mailing Address - Phone:763-712-5986
Mailing Address - Fax:763-712-3916
Practice Address - Street 1:7533 SUNWOOD DR NW
Practice Address - Street 2:STE. 212
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-4973
Practice Address - Country:US
Practice Address - Phone:763-712-5986
Practice Address - Fax:763-712-3916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN82D29BAOtherBC/BS
MNU79057Medicare PIN