Healthcare Provider Details

I. General information

NPI: 1417301847
Provider Name (Legal Business Name): BACK TO LIFE CHIROPRACTIC L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 INDIAN BOUNDARY RD SUITE 4
CHESTERTON IN
46304-1586
US

IV. Provider business mailing address

761 INDIAN BOUNDARY RD SUITE 4
CHESTERTON IN
46304-1586
US

V. Phone/Fax

Practice location:
  • Phone: 219-728-6649
  • Fax: 888-741-5926
Mailing address:
  • Phone: 219-728-6649
  • Fax: 888-741-5926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08002566A
License Number StateIN

VIII. Authorized Official

Name: JAMES P. GANO
Title or Position: OPERATOR/CHIROPRACTOR
Credential: D.C.
Phone: 219-728-6649