Provider Demographics
NPI:1992290811
Name:BACK TO BASICS CHIROPRACTIC
Entity type:Organization
Organization Name:BACK TO BASICS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:IMAGIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-809-1844
Mailing Address - Street 1:16-590 OLD VOLCANO RD
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-8158
Mailing Address - Country:US
Mailing Address - Phone:408-809-1844
Mailing Address - Fax:
Practice Address - Street 1:16-590 OLD VOLCANO RD
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749
Practice Address - Country:US
Practice Address - Phone:408-809-1844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC-1332111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty