Provider Demographics
NPI:1962407080
Name:BACK, MICHAEL B (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:BACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11802 NE 65TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5521
Mailing Address - Country:US
Mailing Address - Phone:360-253-6883
Mailing Address - Fax:360-892-7040
Practice Address - Street 1:11802 NE 65TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-5521
Practice Address - Country:US
Practice Address - Phone:360-253-6883
Practice Address - Fax:360-892-7040
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002774111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA84058466Medicaid
WA0187146OtherDEPT OF LABOR & INDS.
WAP00169111OtherMEDICARE RAILROAD
WA0187146OtherDEPT OF LABOR & INDS.
WA8804671Medicare ID - Type Unspecified