MEDICARE: BACK TO LIFE CHIROPRACTIC, SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	038010264	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	216661	OTHER	IL	MEDICARE PTAN

General Provider Information

NPI Number	:	1194983650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO LIFE CHIROPRACTIC, SC

Provider Business Mailing Address
First Line	:	454 N IDA LN
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-2210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1352 PATRIOT BLVD
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60026-7777
Country	:	US
Telephone Number	:	847-917-3097
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS GODBOUT III
Credential	:
Telephone Number	:	847-917-3097

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	09/04/2008

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