MEDICARE: BACK IN MOTION CLINIC OF CHIROPRACTIC

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	261QH0100X	Health Service Clinic/Center	3498	SC

General Provider Information

NPI Number	:	1346571338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK IN MOTION CLINIC OF CHIROPRACTIC

Provider Business Mailing Address
First Line	:	PO BOX 1511
Second Line	:
City	:	FOUNTAIN INN
State	:	SC
Zip	:	29644-1058
Country	:	US
Telephone Number	:	864-601-9012
Fax Number	:

Provider Business Practice Location Address
First Line	:	703 FAIRVIEW ST
Second Line	:
City	:	FOUNTAIN INN
State	:	SC
Zip	:	29644-1541
Country	:	US
Telephone Number	:	864-601-9012
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES GEORGE GOLDIZEN II
Credential	:	D.C.
Telephone Number	:	864-601-9012

Provider Enumeration Date	:	01/15/2010
Last Update Date	:	01/15/2010

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