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General NPI Number Information
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NPI Number | 1821229998
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Entity Type | Organization
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Legal Business Name | BACK IN ACTION CHIROPRACTIC
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Dates
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Enumeration Date | 08/06/2009
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Last Update Date | 02/23/2018
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Provider Practice Location Address
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Address Line | 10443 LLINOIS ROAD
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City | FORT WAYNE
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State | IN
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Zip | 46814
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Country | US
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Telephone | 260-625-5144
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Fax | 260-625-5264
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Provider Business Mailing Address
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Address Line | 10443 LLINOIS ROAD
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City | FORT WAYNE
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State | IN
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Zip | 46814
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Country | US
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Telephone | 260-625-5144
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Fax | 260-625-5264
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL RENE O'DONNELL
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Credential | D.C.
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Telephone | 260-625-5144
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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 | 08002467A
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License Number State | IN
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