Provider Demographics
NPI:1871515981
Name:BACK TO HEALTH CHIROPRACTIC P C
Entity type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DIVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-258-0014
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-0128
Mailing Address - Country:US
Mailing Address - Phone:405-258-0014
Mailing Address - Fax:405-258-0094
Practice Address - Street 1:1206 MANVEL AVE STE B
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-4401
Practice Address - Country:US
Practice Address - Phone:405-258-0014
Practice Address - Fax:405-258-0094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3592111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK446605938 003OtherBLUE CROSS/BLUE SHIELD
OKP00135785 DB9021OtherRAILROAD MEDICARE
OKP00135785 DB9021OtherRAILROAD MEDICARE