Provider Demographics
NPI:1356531404
Name:BACK TO HEALTH WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:BACK TO HEALTH WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-257-9199
Mailing Address - Street 1:755 NORTH AVE
Mailing Address - Street 2:STE B
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-3152
Mailing Address - Country:US
Mailing Address - Phone:970-257-9199
Mailing Address - Fax:970-257-1880
Practice Address - Street 1:755 NORTH AVE
Practice Address - Street 2:STE B
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-3152
Practice Address - Country:US
Practice Address - Phone:970-257-9199
Practice Address - Fax:970-257-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO523828Medicare PIN