Provider Demographics
NPI:1902086390
Name:BACK TO HEALTH CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMENICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-636-2190
Mailing Address - Street 1:9037 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-8869
Mailing Address - Country:US
Mailing Address - Phone:810-636-2190
Mailing Address - Fax:810-636-7855
Practice Address - Street 1:9037 S STATE RD
Practice Address - Street 2:
Practice Address - City:GOODRICH
Practice Address - State:MI
Practice Address - Zip Code:48438-8869
Practice Address - Country:US
Practice Address - Phone:810-636-2190
Practice Address - Fax:810-636-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0999848OtherHEALTH PLUS
MI0999848OtherHEALTH PLUS
MIV02211Medicare UPIN