MEDICARE: BACK TO BASICS S.C.

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

General Provider Information

NPI Number	:	1326123084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO BASICS S.C.

Provider Business Mailing Address
First Line	:	PO BOX 8844
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54308-8844
Country	:	US
Telephone Number	:	920-465-1431
Fax Number	:	920-468-0405

Provider Business Practice Location Address
First Line	:	1792 E MASON ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-3251
Country	:	US
Telephone Number	:	920-465-1431
Fax Number	:	920-468-0405

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSEPH JOHN MILLAN III
Credential	:	D.C.
Telephone Number	:	920-465-1431

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	08/22/2020

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