MEDICARE: BACK TO HEALTH WELLNESS CENTER, LLC

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	4322	CO

General Provider Information

NPI Number	:	1356531404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO HEALTH WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	755 NORTH AVE
Second Line	:	STE B
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-3152
Country	:	US
Telephone Number	:	970-257-9199
Fax Number	:	970-257-1880

Provider Business Practice Location Address
First Line	:	755 NORTH AVE
Second Line	:	STE B
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-3152
Country	:	US
Telephone Number	:	970-257-9199
Fax Number	:	970-257-1880

Authorized Official
Title or Position	:	MANAGING OWNER
Name	:	DR. DANIEL LONQUIST
Credential	:	D.C.
Telephone Number	:	970-257-9199

Provider Enumeration Date	:	07/25/2007
Last Update Date	:	12/07/2009

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