Provider Demographics
NPI:1073259198
Name:BACK TO WELLNESS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:BACK TO WELLNESS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPERATOR/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MODICA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:828-333-1250
Mailing Address - Street 1:105 CASTLEROCK DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-9517
Mailing Address - Country:US
Mailing Address - Phone:828-333-1250
Mailing Address - Fax:828-278-4065
Practice Address - Street 1:123D ACTON CIR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-1043
Practice Address - Country:US
Practice Address - Phone:828-278-4078
Practice Address - Fax:828-278-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
119152270OtherCAQH