Provider Demographics
NPI:1265518229
Name:HEALTHY BACK, INC.
Entity type:Organization
Organization Name:HEALTHY BACK, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:DEITZ
Authorized Official - Last Name:CROMSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-371-2525
Mailing Address - Street 1:PO BOX 1378
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-1378
Mailing Address - Country:US
Mailing Address - Phone:910-371-2525
Mailing Address - Fax:910-371-5922
Practice Address - Street 1:304 VILLAGE ROAD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-1378
Practice Address - Country:US
Practice Address - Phone:910-371-2525
Practice Address - Fax:910-371-5922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790183LMedicaid
NC2448967AMedicare ID - Type Unspecified
NC790183LMedicaid