Provider Demographics
NPI:1497937767
Name:BACK TO LIFE, INCORPORATED
Entity Type:Organization
Organization Name:BACK TO LIFE, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACIE
Authorized Official - Middle Name:PADILLA
Authorized Official - Last Name:CONTRERAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-594-4870
Mailing Address - Street 1:PO BOX 8237
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85066-8237
Mailing Address - Country:US
Mailing Address - Phone:623-594-4870
Mailing Address - Fax:623-444-9213
Practice Address - Street 1:5915 W ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85035-1639
Practice Address - Country:US
Practice Address - Phone:623-594-4870
Practice Address - Fax:623-444-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2772322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ143580Medicaid