Provider Demographics
NPI:1902963812
Name:BACK IN ACTION CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:BACK IN ACTION CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-336-9355
Mailing Address - Street 1:111 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2201
Mailing Address - Country:US
Mailing Address - Phone:920-336-9355
Mailing Address - Fax:920-336-9358
Practice Address - Street 1:111 N 5TH ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2201
Practice Address - Country:US
Practice Address - Phone:920-336-9355
Practice Address - Fax:920-336-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3652-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty