Provider Demographics
NPI:1457773871
Name:BACK TO HEALTH CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DCMCS-P
Authorized Official - Phone:417-532-2986
Mailing Address - Street 1:617 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-2745
Mailing Address - Country:US
Mailing Address - Phone:417-532-2986
Mailing Address - Fax:417-532-2271
Practice Address - Street 1:617 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-2745
Practice Address - Country:US
Practice Address - Phone:417-532-2986
Practice Address - Fax:417-532-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005229111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000032217Medicare UPIN