Provider Demographics
NPI:1871668400
Name:BACK IN LINE CHIROPRACTIC PC
Entity type:Organization
Organization Name:BACK IN LINE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-768-8858
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-0365
Mailing Address - Country:US
Mailing Address - Phone:313-768-8858
Mailing Address - Fax:
Practice Address - Street 1:712 E. 9 MILE RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030
Practice Address - Country:US
Practice Address - Phone:248-556-5890
Practice Address - Fax:248-556-5891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14493280Medicaid
MI0P37990OtherBCBS
MI1760598171OtherOUAIS NPI
MI=========OtherTAX IDENTIFICATION NUMBER
MI14493280Medicaid