Provider Demographics
NPI:1962796870
Name:BACK WELLNESS CENTER PC
Entity type:Organization
Organization Name:BACK WELLNESS CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WODA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-724-8925
Mailing Address - Street 1:23100 CHERRY HILL ST STE 4
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1449
Mailing Address - Country:US
Mailing Address - Phone:313-724-8925
Mailing Address - Fax:313-724-8926
Practice Address - Street 1:23100 CHERRY HILL ST STE 4
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1449
Practice Address - Country:US
Practice Address - Phone:313-724-8925
Practice Address - Fax:313-724-8926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007303111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3489405Medicaid
MI0H25371OtherBCBS