Healthcare Provider Details

I. General information

NPI: 1194983650
Provider Name (Legal Business Name): BACK TO LIFE CHIROPRACTIC, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1352 PATRIOT BLVD
GLENVIEW IL
60026-7777
US

IV. Provider business mailing address

454 N IDA LN
ELMHURST IL
60126-2210
US

V. Phone/Fax

Practice location:
  • Phone: 847-917-3097
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038010264
License Number StateIL

VIII. Authorized Official

Name: THOMAS GODBOUT III
Title or Position: PRESIDENT
Credential:
Phone: 847-917-3097