Healthcare Provider Details

I. General information

NPI: 1285903070
Provider Name (Legal Business Name): BACK ACRES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 E. MARKET STREET
LOGANSPORT IN
46947-2356
US

IV. Provider business mailing address

4415 E. MARKET STREET
LOGANSPORT IN
46947-2356
US

V. Phone/Fax

Practice location:
  • Phone: 574-753-4871
  • Fax: 574-753-4871
Mailing address:
  • Phone: 574-753-4871
  • Fax: 574-753-4871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number482
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number482
License Number StateIN

VIII. Authorized Official

Name: RONALD C. BROWN
Title or Position: OWNER
Credential: D.C.
Phone: 574-753-4871