Provider Demographics
NPI:1518247873
Name:BACK IN FORM PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:BACK IN FORM PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-231-3676
Mailing Address - Street 1:4445 HIGHWAY A1A
Mailing Address - Street 2:SUITE 125
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-5405
Mailing Address - Country:US
Mailing Address - Phone:772-231-3676
Mailing Address - Fax:772-231-3670
Practice Address - Street 1:4445 HIGHWAY A1A
Practice Address - Street 2:SUITE 125
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-5405
Practice Address - Country:US
Practice Address - Phone:772-231-3676
Practice Address - Fax:772-231-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT18268OtherSTATE LICENSE
FLPT18370OtherSTATE LICENSE
FLPT18268OtherSTATE LICENSE
FLY8172YMedicare PIN