Provider Demographics
NPI:1013111764
Name:BACK TO HEALTH CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-359-2264
Mailing Address - Street 1:60 S 2ND W
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1819
Mailing Address - Country:US
Mailing Address - Phone:208-359-2264
Mailing Address - Fax:
Practice Address - Street 1:60 S 2ND W
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1819
Practice Address - Country:US
Practice Address - Phone:208-359-2264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010019702OtherBLUE SHIELD
IDC8042OtherBLUE CROSS
IDC8042OtherBLUE CROSS