=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679083588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK IN ACTION CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2017
-----------------------------------------------------
Last Update Date | 10/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 W SEMINARY ST
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-223-0199
-----------------------------------------------------
Fax | 660-438-6943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 729
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65355-0729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-223-0199
-----------------------------------------------------
Fax | 660-438-6943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | DR. TYREL JAMES REICHERT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 660-223-0199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2015044724
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------