=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063554343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK IN ACTION HOLISTIC HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 E STATE ST SUITE 101
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-397-8500
-----------------------------------------------------
Fax | 815-397-8588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5301 E STATE ST SUITE 101
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-397-8500
-----------------------------------------------------
Fax | 815-397-8588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. SHELLY R VANDERVORT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-397-8500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------