=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336552066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK TO BASICS COMMUNITY CLINIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2014
-----------------------------------------------------
Last Update Date | 06/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 181 E NORTH WATER ST SUITE 115
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-2722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-637-1084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 181 E NORTH WATER ST SUITE 115
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-2722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-637-1084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KIMBERLY CONN FLETCHER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 920-420-5751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 472012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------