Provider Demographics
NPI:1447476445
Name:BACK TO LIFE
Entity type:Organization
Organization Name:BACK TO LIFE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CAVACIUTI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-345-4520
Mailing Address - Street 1:110 PROMINENCE POINT PKWY STE 122
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9076
Mailing Address - Country:US
Mailing Address - Phone:770-345-4520
Mailing Address - Fax:770-345-4524
Practice Address - Street 1:110 PROMINENCE POINT PKWY STE 122
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-9076
Practice Address - Country:US
Practice Address - Phone:770-345-4520
Practice Address - Fax:770-345-4524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007378111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6970Medicare UPIN