=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194197376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATURAL PAIN BACK INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2015
-----------------------------------------------------
Last Update Date | 10/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3535 E NEW YORK ST SUITE 216
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-4465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-843-0076
-----------------------------------------------------
Fax | 662-846-7730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 3RD ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38732-2362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-843-0076
-----------------------------------------------------
Fax | 662-846-7730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. REGINALD LAMAR RODGES
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 662-843-0076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------