Healthcare Provider Details

I. General information

NPI: 1447393954
Provider Name (Legal Business Name): BACK TO HEALTH CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S MAIN ST
LYMAN WY
82937-1194
US

IV. Provider business mailing address

PO BOX 1194
LYMAN WY
82937-1194
US

V. Phone/Fax

Practice location:
  • Phone: 307-787-6400
  • Fax: 307-787-6401
Mailing address:
  • Phone: 307-787-6400
  • Fax: 307-787-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number611
License Number StateWY

VIII. Authorized Official

Name: JASON R. HAYCOCK
Title or Position: PRESIDENT
Credential: D.C.
Phone: 307-787-6400