Provider Demographics
NPI:1922254929
Name:BACK CARE CENTER, INC.
Entity Type:Organization
Organization Name:BACK CARE CENTER, INC.
Other - Org Name:RESERVOIR CHIROPRACTIC-BACK CARE CENTER, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:V
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, D C
Authorized Official - Phone:601-992-3050
Mailing Address - Street 1:1149 OLD FANNIN RD
Mailing Address - Street 2:SUITE 22
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-9244
Mailing Address - Country:US
Mailing Address - Phone:601-992-3050
Mailing Address - Fax:601-992-3051
Practice Address - Street 1:1149 OLD FANNIN RD
Practice Address - Street 2:SUITE 22
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-9244
Practice Address - Country:US
Practice Address - Phone:601-992-3050
Practice Address - Fax:601-992-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS350000104OtherMEDICARE IDENTIFICATION NUMBER