MEDICARE: BACK N SHAPE SPORTSMED

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	0104001623	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	115137	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1366505182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK N SHAPE SPORTSMED

Provider Business Mailing Address
First Line	:	3809 PRINCESS ANNE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-1900
Country	:	US
Telephone Number	:	757-471-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	3809 PRINCESS ANNE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-1900
Country	:	US
Telephone Number	:	757-471-2800
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOSEPH W MARCIL
Credential	:	D.C.
Telephone Number	:	757-471-2800

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	08/22/2020

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1891972543 — AMERICARE MEDICAL SUPPLIES & SERVICES INC
Practice Location Address:

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Directions to “BACK N SHAPE SPORTSMED ” Practice Location

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