MEDICARE: BACK HEALTH CHIROPRACTIC, 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	5608	AZ

General Provider Information

NPI Number	:	1467780197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK HEALTH CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	4503 N 32ND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-3339
Country	:	US
Telephone Number	:	602-956-8222
Fax Number	:	602-956-8333

Provider Business Practice Location Address
First Line	:	4503 N 32ND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-3339
Country	:	US
Telephone Number	:	602-956-8222
Fax Number	:	602-956-8333

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	GOUDARZ VASSIGH
Credential	:	D.C.
Telephone Number	:	602-956-8222

Provider Enumeration Date	:	11/18/2009
Last Update Date	:	11/18/2009

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