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General NPI Number Information
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NPI Number | 1417301847
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Entity Type | Organization
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Legal Business Name | BACK TO LIFE CHIROPRACTIC L.L.C
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Dates
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Enumeration Date | 04/22/2016
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 761 INDIAN BOUNDARY RD SUITE 4
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City | CHESTERTON
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State | IN
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Zip | 46304-1586
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Country | US
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Telephone | 219-728-6649
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Fax | 888-741-5926
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Provider Business Mailing Address
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Address Line | 761 INDIAN BOUNDARY RD SUITE 4
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City | CHESTERTON
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State | IN
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Zip | 46304-1586
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Country | US
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Telephone | 219-728-6649
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Fax | 888-741-5926
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Authorized Official
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Title or Position | OPERATOR/CHIROPRACTOR
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Name | JAMES P. GANO
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Credential | D.C.
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Telephone | 219-728-6649
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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 | 08002566A
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License Number State | IN
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