MEDICARE: BACK TO HEALTH PC

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	111N00000X	Chiropractor	2004003311	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33757039	OTHER	MO	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1275566077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO HEALTH PC

Provider Business Mailing Address
First Line	:	1727 W JESSE JAMES RD
Second Line	:	SUITE 5
City	:	EXCELSIOR SPRINGS
State	:	MO
Zip	:	64024-1846
Country	:	US
Telephone Number	:	816-630-2225
Fax Number	:	816-637-2225

Provider Business Practice Location Address
First Line	:	1727 W JESSE JAMES RD
Second Line	:	SUITE 5
City	:	EXCELSIOR SPRINGS
State	:	MO
Zip	:	64024-1846
Country	:	US
Telephone Number	:	816-630-2225
Fax Number	:	816-637-2225

Authorized Official
Title or Position	:	PRESIDENT CHIROPRACTOR
Name	:	DEVIN DEAN BOWMAN
Credential	:	DC
Telephone Number	:	816-630-2225

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	08/22/2020

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