Organization
BACK TO LIFE CHIROPRACTIC, SC
Active
Organization
BACK TO LIFE CHIROPRACTIC, SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THOMAS GODBOUT III (PRESIDENT)
(847) 917-3097
Entity
Organization
Contact information
Practice address
1352 PATRIOT BLVD, GLENVIEW, IL 60026-7777
(847) 917-3097
Mailing address
454 N IDA LN, ELMHURST, IL 60126-2210
Taxonomy
Speciality
Code
Description
License number
State
111NS0005X
Sports Physician Chiropractor
Primary
038010264
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
216661
MEDICARE PTAN
IL
Enumeration date
05/30/2008
Last updated
09/04/2008
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