Healthcare Provider Details

I. General information

NPI: 1740899475
Provider Name (Legal Business Name): BACK 2 WORK CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 E RIVERSIDE DR
EAGLE ID
83616-6020
US

IV. Provider business mailing address

PO BOX 382
MERIDIAN ID
83680-0382
US

V. Phone/Fax

Practice location:
  • Phone: 208-965-2262
  • Fax: 208-963-3299
Mailing address:
  • Phone: 208-576-4696
  • Fax: 208-963-3299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. XAVIER A ORTIZ RAMIREZ
Title or Position: CEO
Credential: DC
Phone: 208-965-2262