Provider Demographics
NPI:1194262857
Name:INDIANA BACKTOWELLNESS
Entity type:Organization
Organization Name:INDIANA BACKTOWELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KACI
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:RUCK-CHALFANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-440-9256
Mailing Address - Street 1:238 DEMAREST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-2930
Mailing Address - Country:US
Mailing Address - Phone:260-440-9256
Mailing Address - Fax:
Practice Address - Street 1:238 DEMAREST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-2930
Practice Address - Country:US
Practice Address - Phone:260-440-9256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002819A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty