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General NPI Number Information
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NPI Number | 1033821467
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Entity Type | Organization
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Legal Business Name | BACK 40 CHIROPRACTIC CLINIC, PLLC
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Dates
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Enumeration Date | 12/16/2022
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Last Update Date | 06/14/2023
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Provider Practice Location Address
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Address Line | 3406 BELLA VISTA WAY
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City | BELLA VISTA
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State | AR
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Zip | 72714-5700
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Country | US
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Telephone | 479-888-8122
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Fax | 479-487-0615
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Provider Business Mailing Address
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Address Line | 51 TAYLOR DR
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City | BELLA VISTA
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State | AR
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Zip | 72714-3242
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Country | US
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Telephone | 808-779-0144
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MATTHEW PAUL TUTTLE
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Credential | DC
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Telephone | 479-888-8122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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