Provider Demographics
NPI:1457592297
Name:BACK, ROGER
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:BACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 N BROWN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-2826
Mailing Address - Country:US
Mailing Address - Phone:937-520-4803
Mailing Address - Fax:
Practice Address - Street 1:37 N BROWN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-2826
Practice Address - Country:US
Practice Address - Phone:937-520-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH304720163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse