Provider Demographics
NPI:1407211097
Name:BACK TO FORM PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:BACK TO FORM PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-291-8656
Mailing Address - Street 1:485 CENTRAL PARK W APT 3F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3360
Mailing Address - Country:US
Mailing Address - Phone:212-227-7310
Mailing Address - Fax:917-591-4477
Practice Address - Street 1:18 E 41ST ST
Practice Address - Street 2:SUITE 406
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6222
Practice Address - Country:US
Practice Address - Phone:212-725-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-23
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty