Provider Demographics
NPI:1104080688
Name:BACK ON TRACK CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:BACK ON TRACK CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-742-3733
Mailing Address - Street 1:108 FRONT STREET
Mailing Address - Street 2:SUITE101
Mailing Address - City:LABADIE
Mailing Address - State:MO
Mailing Address - Zip Code:63055-1301
Mailing Address - Country:US
Mailing Address - Phone:636-742-3733
Mailing Address - Fax:
Practice Address - Street 1:108 FRONT STREET
Practice Address - Street 2:SUITE101
Practice Address - City:LABADIE
Practice Address - State:MO
Practice Address - Zip Code:63055-1301
Practice Address - Country:US
Practice Address - Phone:636-742-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008010491111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty