Provider Demographics
NPI:1467857086
Name:BACKROAD HEALTH CARE
Entity Type:Organization
Organization Name:BACKROAD HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVRILKA
Authorized Official - Suffix:
Authorized Official - Credentials:APN, FNP-C
Authorized Official - Phone:618-545-0707
Mailing Address - Street 1:7825A EAST GRANT ROAD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILL
Mailing Address - State:IL
Mailing Address - Zip Code:62893
Mailing Address - Country:US
Mailing Address - Phone:618-545-0707
Mailing Address - Fax:
Practice Address - Street 1:7825A EAST GRANT ROAD
Practice Address - Street 2:
Practice Address - City:WALNUT HILL
Practice Address - State:IL
Practice Address - Zip Code:62893
Practice Address - Country:US
Practice Address - Phone:618-545-0707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010715363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty