Provider Demographics
NPI:1083882450
Name:BACK IN ACTION PHYSICAL THERAPY AND FITNESS CENTER,LLC
Entity Type:Organization
Organization Name:BACK IN ACTION PHYSICAL THERAPY AND FITNESS CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:K
Authorized Official - Last Name:LATCHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:814-684-0702
Mailing Address - Street 1:1407 EISENHOWER BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3262
Mailing Address - Country:US
Mailing Address - Phone:814-684-0702
Mailing Address - Fax:814-684-0426
Practice Address - Street 1:BUILDING II, ROUTE 220
Practice Address - Street 2:TIPTON MEDICAL & DIAGNOSTIC CENTER
Practice Address - City:TIPTON
Practice Address - State:PA
Practice Address - Zip Code:16684
Practice Address - Country:US
Practice Address - Phone:814-684-0702
Practice Address - Fax:814-684-0426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015991L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPT015991LOtherLICENSE NUMBER