Healthcare Provider Details

I. General information

NPI: 1043515505
Provider Name (Legal Business Name): BACK IN ACTION CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E FILLMORE ST
COLORADO SPRINGS CO
80907-6375
US

IV. Provider business mailing address

824 E FILLMORE ST
COLORADO SPRINGS CO
80907-6375
US

V. Phone/Fax

Practice location:
  • Phone: 719-634-2579
  • Fax: 719-634-2371
Mailing address:
  • Phone: 719-634-2579
  • Fax: 719-342-2379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number6562
License Number StateCO

VIII. Authorized Official

Name: DR. JASON R GILLIES
Title or Position: OWNER/CHIROPRACTOR
Credential: D.C.
Phone: 719-634-2579