Provider Demographics
NPI:1063698579
Name:BACK TO LIFE CHIROPRACTIC
Entity type:Organization
Organization Name:BACK TO LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-933-4777
Mailing Address - Street 1:33 W KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:MOUNT EPHRAIM
Mailing Address - State:NJ
Mailing Address - Zip Code:08059-1304
Mailing Address - Country:US
Mailing Address - Phone:856-933-4777
Mailing Address - Fax:
Practice Address - Street 1:33 W KINGS HWY
Practice Address - Street 2:
Practice Address - City:MOUNT EPHRAIM
Practice Address - State:NJ
Practice Address - Zip Code:08059-1304
Practice Address - Country:US
Practice Address - Phone:856-933-4777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00591900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065507Medicare PIN