Provider Demographics
NPI:1417396581
Name:BACK ON TRACK PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:BACK ON TRACK PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:541-573-1543
Mailing Address - Street 1:559 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1441
Mailing Address - Country:US
Mailing Address - Phone:541-573-1543
Mailing Address - Fax:541-573-1263
Practice Address - Street 1:559 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1441
Practice Address - Country:US
Practice Address - Phone:541-573-1543
Practice Address - Fax:541-573-1263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR03498261QP2000X
OR05197261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy