MEDICARE: BACK AND NECK PAIN RELIEF CENTER

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	08001269A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	U01388	OTHER	IN	UPIN

General Provider Information

NPI Number	:	1316119530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK AND NECK PAIN RELIEF CENTER

Provider Business Mailing Address
First Line	:	4705 INDIANAPOLIS BLVD
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3385
Country	:	US
Telephone Number	:	219-398-2273
Fax Number	:	219-398-3350

Provider Business Practice Location Address
First Line	:	4705 INDIANAPOLIS BLVD
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3385
Country	:	US
Telephone Number	:	219-398-2273
Fax Number	:	219-398-3350

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. ROBERT SCOTT MARTIN
Credential	:	D.C.
Telephone Number	:	219-398-2273

Provider Enumeration Date	:	03/27/2008
Last Update Date	:	03/27/2008

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