Provider Demographics
NPI:1245440502
Name:BACK TO LIFE CHIROPRACTIC PC
Entity type:Organization
Organization Name:BACK TO LIFE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-430-0018
Mailing Address - Street 1:333 MAIN ST N STE 203
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5054
Mailing Address - Country:US
Mailing Address - Phone:651-430-0018
Mailing Address - Fax:651-430-0019
Practice Address - Street 1:333 MAIN ST N STE 203
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5054
Practice Address - Country:US
Practice Address - Phone:651-430-0018
Practice Address - Fax:651-430-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC3791111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty