MEDICARE: BACK & JOINT REHAB CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	08002901A	IN

General Provider Information

NPI Number	:	1144775867
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK & JOINT REHAB CENTER LLC

Provider Business Mailing Address
First Line	:	17311 MICHAEL DR
Second Line	:
City	:	LOWELL
State	:	IN
Zip	:	46356-7511
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	127 E 113TH AVE
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-9706
Country	:	US
Telephone Number	:	219-331-6041
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	DR. ARTEMIO DEL REAL
Credential	:	DC
Telephone Number	:	219-331-6041

Provider Enumeration Date	:	08/23/2016
Last Update Date	:	08/23/2016

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