Provider Demographics
NPI:1932251303
Name:BACK ON TRACK CHIROPRACTIC PC
Entity Type:Organization
Organization Name:BACK ON TRACK CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCOIX
Authorized Official - Middle Name:
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-562-0502
Mailing Address - Street 1:1684 REUNION AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4608
Mailing Address - Country:US
Mailing Address - Phone:801-562-0502
Mailing Address - Fax:801-302-8265
Practice Address - Street 1:1684 REUNION AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4608
Practice Address - Country:US
Practice Address - Phone:801-562-0502
Practice Address - Fax:801-302-8265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT320003-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870395551005Medicaid