Provider Demographics
NPI:1427002534
Name:BACK TO HEALTH CHIROPRACTIC, P.A.
Entity type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CLUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:785-989-4644
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:WATHENA
Mailing Address - State:KS
Mailing Address - Zip Code:66090-0100
Mailing Address - Country:US
Mailing Address - Phone:785-989-4644
Mailing Address - Fax:785-989-4660
Practice Address - Street 1:324 SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:WATHENA
Practice Address - State:KS
Practice Address - Zip Code:66090-1280
Practice Address - Country:US
Practice Address - Phone:785-989-4644
Practice Address - Fax:785-989-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK01-04749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS060911OtherINDIVIDUAL MEDICARE PIN
U85487Medicare UPIN
KS660021Medicare PIN