Provider Demographics
NPI:1902805088
Name:BACK 2 BACK CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BACK 2 BACK CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-797-1000
Mailing Address - Street 1:RR 1 BOX 458
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-9721
Mailing Address - Country:US
Mailing Address - Phone:570-797-1000
Mailing Address - Fax:570-797-4977
Practice Address - Street 1:RR 1 BOX 458
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-9721
Practice Address - Country:US
Practice Address - Phone:570-797-1000
Practice Address - Fax:570-797-4977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 008791111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101192963-001Medicaid
PARE1596111OtherBLUE CROSS BLUE SHIELD
PABA080155Medicare ID - Type Unspecified
PARE1596111OtherBLUE CROSS BLUE SHIELD