Provider Demographics
NPI:1124225008
Name:BACK IN ACTION OF SCOTTSDALE LLC
Entity Type:Organization
Organization Name:BACK IN ACTION OF SCOTTSDALE LLC
Other - Org Name:BACK IN ACTION PAIN THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:W
Authorized Official - Last Name:FANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-513-4801
Mailing Address - Street 1:8711 E PINNACLE PEAK RD PMB 105
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-3517
Mailing Address - Country:US
Mailing Address - Phone:480-513-4801
Mailing Address - Fax:480-513-4867
Practice Address - Street 1:2340 E BEARDSLEY RD STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-1286
Practice Address - Country:US
Practice Address - Phone:480-513-4801
Practice Address - Fax:480-513-4867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ437521Medicaid