Healthcare Provider Details

I. General information

NPI: 1437793932
Provider Name (Legal Business Name): BACK AND NECK PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 MEMORIAL BLVD N
MARTINSVILLE VA
24112-2429
US

IV. Provider business mailing address

1141 MEMORIAL BLVD N
MARTINSVILLE VA
24112-2429
US

V. Phone/Fax

Practice location:
  • Phone: 276-632-3334
  • Fax: 276-632-1882
Mailing address:
  • Phone: 276-632-3334
  • Fax: 276-632-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JAPHET DIVAD LEGRANT
Title or Position: OWNER
Credential: DC
Phone: 276-632-3334