Provider Demographics
NPI:1417069980
Name:BACK TO BASICS CHIROPRACTIC CENTER, PA
Entity type:Organization
Organization Name:BACK TO BASICS CHIROPRACTIC CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:BOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:919-303-2500
Mailing Address - Street 1:211 S SALEM ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-1878
Mailing Address - Country:US
Mailing Address - Phone:919-303-2500
Mailing Address - Fax:919-303-2501
Practice Address - Street 1:211 S SALEM ST
Practice Address - Street 2:SUITE C
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1878
Practice Address - Country:US
Practice Address - Phone:919-303-2500
Practice Address - Fax:919-303-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2899111N00000X
NC3237111N00000X
NC1939111N00000X
NC3428111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2334228Medicare ID - Type UnspecifiedGROUP ID