Provider Demographics
NPI:1043739436
Name:BACK ON TRACK THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:BACK ON TRACK THERAPY AND WELLNESS, LLC
Other - Org Name:BACK ON TRACK PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-356-4385
Mailing Address - Street 1:3477 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-3706
Mailing Address - Country:US
Mailing Address - Phone:567-356-4385
Mailing Address - Fax:419-738-8002
Practice Address - Street 1:3477 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3706
Practice Address - Country:US
Practice Address - Phone:567-356-4385
Practice Address - Fax:419-738-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-17
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT016035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty