Provider Demographics
NPI:1962560284
Name:BACK 2 BACK CHIROPRACTIC GROUP LLC
Entity type:Organization
Organization Name:BACK 2 BACK CHIROPRACTIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:BALTICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-799-1999
Mailing Address - Street 1:206 JOE V KNOX AVENUE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9148
Mailing Address - Country:US
Mailing Address - Phone:704-799-1999
Mailing Address - Fax:704-663-8225
Practice Address - Street 1:206 JOE V KNOX AVENUE
Practice Address - Street 2:SUITE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-799-1999
Practice Address - Fax:704-663-8225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC98014NPMedicaid
NC2455549Medicare ID - Type Unspecified
NC98014NPMedicaid