Provider Demographics
NPI:1962582296
Name:BACK TO HEALTH CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BANASIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:951-587-2225
Mailing Address - Street 1:27450 YNEZ RD
Mailing Address - Street 2:116
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591
Mailing Address - Country:US
Mailing Address - Phone:951-587-2225
Mailing Address - Fax:
Practice Address - Street 1:27450 YNEZ RD
Practice Address - Street 2:116
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4649
Practice Address - Country:US
Practice Address - Phone:951-587-2225
Practice Address - Fax:951-587-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0236250OtherBLUE SHIELD
CADC0236250Medicare ID - Type Unspecified
CADC0236250OtherBLUE SHIELD
CA6199840001Medicare NSC