Provider Demographics
NPI:1063554343
Name:BACK IN ACTION HOLISTIC HEALTH CENTER
Entity type:Organization
Organization Name:BACK IN ACTION HOLISTIC HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDERVORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-397-8500
Mailing Address - Street 1:5301 E STATE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-397-8500
Mailing Address - Fax:815-397-8588
Practice Address - Street 1:5301 E STATE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-397-8500
Practice Address - Fax:815-397-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID
207230Medicare ID - Type Unspecified