Provider Demographics
NPI:1417998329
Name:BACK TO BASICS FAMILY PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:BACK TO BASICS FAMILY PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-985-0500
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24077-0358
Mailing Address - Country:US
Mailing Address - Phone:540-985-0500
Mailing Address - Fax:540-985-0529
Practice Address - Street 1:1015 FIRST STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4427
Practice Address - Country:US
Practice Address - Phone:540-985-0500
Practice Address - Fax:540-985-0529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004995208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09023Medicare PIN