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General NPI Number Information
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NPI Number | 1730588328
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Entity Type | Organization
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Legal Business Name | BACK TO BASICS CHIROPRACTIC AND SPORTS REHABILITATION LLC
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Dates
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Enumeration Date | 08/19/2014
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Last Update Date | 02/19/2019
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Provider Practice Location Address
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Address Line | 800 STERTHAUS DR SUITE A
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City | ORMOND BEACH
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State | FL
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Zip | 32174-5132
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Country | US
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Telephone | 386-310-4884
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Fax | 386-872-7647
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Provider Business Mailing Address
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Address Line | 800 STERTHAUS DR SUITE A
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City | ORMOND BEACH
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State | FL
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Zip | 32174-5132
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Country | US
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Telephone | 386-310-4884
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Fax | 386-872-7647
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Authorized Official
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Title or Position | OWNER
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Name | DR. RYAN IMHOFF
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Credential | D.C.
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Telephone | 386-871-1174
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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 | CH9482
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License Number State | FL
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