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General NPI Number Information
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NPI Number | 1073821260
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Entity Type | Organization
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Legal Business Name | BACK TO LIFE NATURAL HEALTH CENTER
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Dates
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Enumeration Date | 09/22/2010
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Last Update Date | 09/22/2010
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Provider Practice Location Address
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Address Line | 2960 WINNETKA AVE N SUITE 110
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City | CRYSTAL
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State | MN
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Zip | 55427
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Country | US
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Telephone | 763-546-3736
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Fax | 763-546-3807
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Provider Business Mailing Address
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Address Line | 2960 WINNETKA AVE N SUITE 110
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City | CRYSTAL
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State | MN
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Zip | 55427
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Country | US
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Telephone | 763-546-3736
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Fax | 763-546-3807
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | RONALD DENIS LEDOUX
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Credential | DC
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Telephone | 763-546-3736
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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 | 3691
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License Number State | MN
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