Healthcare Provider Details

I. General information

NPI: 1730212242
Provider Name (Legal Business Name): BACK TO BALANCE CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1158 26TH ST #149
SANTA MONICA CA
90403-4621
US

IV. Provider business mailing address

1158 26TH ST #149
SANTA MONICA CA
90403-4621
US

V. Phone/Fax

Practice location:
  • Phone: 310-460-7353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC19698
License Number StateCA

VIII. Authorized Official

Name: ERIC BADENER
Title or Position: DIRECTOR
Credential: D.C.
Phone: 310-460-7353