Provider Demographics
NPI:1730588328
Name:BACK TO BASICS CHIROPRACTIC AND SPORTS REHABILITATION LLC
Entity type:Organization
Organization Name:BACK TO BASICS CHIROPRACTIC AND SPORTS REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IMHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-871-1174
Mailing Address - Street 1:800 STERTHAUS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5132
Mailing Address - Country:US
Mailing Address - Phone:386-310-4884
Mailing Address - Fax:386-872-7647
Practice Address - Street 1:800 STERTHAUS DR
Practice Address - Street 2:SUITE A
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5132
Practice Address - Country:US
Practice Address - Phone:386-310-4884
Practice Address - Fax:386-872-7647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty