Provider Demographics
NPI:1275513368
Name:THE BACK CLINIC, INC.
Entity Type:Organization
Organization Name:THE BACK CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:HASSERT
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:302-995-2100
Mailing Address - Street 1:5550 KIRKWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5002
Mailing Address - Country:US
Mailing Address - Phone:302-995-2100
Mailing Address - Fax:302-998-3104
Practice Address - Street 1:5550 KIRKWOOD HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5002
Practice Address - Country:US
Practice Address - Phone:302-995-2100
Practice Address - Fax:302-998-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000928226Medicaid
DE0000928226Medicaid