MEDICARE: BACK TO BALANCE CHIROPRACTIC

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	DC19698	CA

General Provider Information

NPI Number	:	1730212242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO BALANCE CHIROPRACTIC

Provider Business Mailing Address
First Line	:	1158 26TH ST
Second Line	:	#149
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4621
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1158 26TH ST
Second Line	:	#149
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4621
Country	:	US
Telephone Number	:	310-460-7353
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ERIC BADENER
Credential	:	D.C.
Telephone Number	:	310-460-7353

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	06/30/2008

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