=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407954704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK TO HEALTH WELLNESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 E. BERTRAND
-----------------------------------------------------
City | ST. MARYS
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-437-6162
-----------------------------------------------------
Fax | 785-437-6197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 503 E. BERTRAND
-----------------------------------------------------
City | ST. MARYS
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-437-6162
-----------------------------------------------------
Fax | 785-437-6197
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PATRICK D QUALLS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 785-437-6162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 01-04398
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------