Provider Demographics
NPI:1295227387
Name:BACK TO HEALTH MEDICAL CARE PC
Entity Type:Organization
Organization Name:BACK TO HEALTH MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TANZA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-654-2410
Mailing Address - Street 1:665 TREEHOUSE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6837
Mailing Address - Country:US
Mailing Address - Phone:904-654-2410
Mailing Address - Fax:
Practice Address - Street 1:690 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2371
Practice Address - Country:US
Practice Address - Phone:516-308-7540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26448208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty