MEDICARE: BACK TO HEALTH CHIROPRACTIC P 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	3592	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00135785 DB9021	OTHER	OK	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	446605938 003	OTHER	OK	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1871515981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO HEALTH CHIROPRACTIC P C

Provider Business Mailing Address
First Line	:	PO BOX 128
Second Line	:
City	:	CHANDLER
State	:	OK
Zip	:	74834-0128
Country	:	US
Telephone Number	:	405-258-0014
Fax Number	:	405-258-0094

Provider Business Practice Location Address
First Line	:	1206 MANVEL AVE STE B
Second Line	:
City	:	CHANDLER
State	:	OK
Zip	:	74834-4401
Country	:	US
Telephone Number	:	405-258-0014
Fax Number	:	405-258-0094

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. ROGER ALLEN DIVIS
Credential	:	D.C.
Telephone Number	:	405-258-0014

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	09/19/2007

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Directions to “BACK TO HEALTH CHIROPRACTIC P C ” Practice Location

Language	Start Address	Practice Location

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