Provider Demographics
NPI:1770796203
Name:BACK TO BASIC HEALTH CHIROPRACTIC
Entity type:Organization
Organization Name:BACK TO BASIC HEALTH CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:VACCARO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-494-6735
Mailing Address - Street 1:PO BOX 2031
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102
Mailing Address - Country:US
Mailing Address - Phone:678-494-6735
Mailing Address - Fax:678-494-6737
Practice Address - Street 1:5101 OLD HWY 5
Practice Address - Street 2:SUITE 1
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:678-494-6735
Practice Address - Fax:678-494-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4718OtherCHIROPRACTIC
GA00804207AMedicaid
GA00804207AMedicaid