Provider Demographics
NPI:1265521447
Name:BACK TO HEALTH CHIROPRACTIC CLINIC, PA
Entity type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARQUARDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-280-6186
Mailing Address - Street 1:5231 E. FRONTAGE HWY 52 RD NW
Mailing Address - Street 2:SUITE 201 &202
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-4156
Mailing Address - Country:US
Mailing Address - Phone:507-280-6186
Mailing Address - Fax:507-280-7682
Practice Address - Street 1:5231 E. FRONTAGE HWY 52 RD NW
Practice Address - Street 2:SUITE 201 &202
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-4156
Practice Address - Country:US
Practice Address - Phone:507-280-6186
Practice Address - Fax:507-280-7682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2554111N00000X
MN208171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2C972MAOtherBCBS OF MN
MN2C972MAOtherBCBS OF MN