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General NPI Number Information
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NPI Number | 1386905412
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Entity Type | Organization
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Legal Business Name | BACK ROOM
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Dates
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Enumeration Date | 06/05/2012
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Last Update Date | 06/13/2012
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Provider Practice Location Address
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Address Line | 15312 DEDEAUX RD SUITE A
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City | GULFPORT
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State | MS
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Zip | 39503-3123
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Country | US
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Telephone | 228-331-2035
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Fax |
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Provider Business Mailing Address
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Address Line | 15312 DEDEAUX RD SUITE A
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City | GULFPORT
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State | MS
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Zip | 39503-3123
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Country | US
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Telephone | 228-331-2035
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | KATANYA FORD
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Credential | D.C.
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Telephone | 228-331-2035
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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 | 1162
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License Number State | MS
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