=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366505182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK N SHAPE SPORTSMED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3809 PRINCESS ANNE RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23456-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-471-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3809 PRINCESS ANNE RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23456-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-471-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH W MARCIL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 757-471-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104001623
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------