Provider Demographics
NPI:1538473632
Name:BACK ON TRACK LLC
Entity Type:Organization
Organization Name:BACK ON TRACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GALINA
Authorized Official - Middle Name:FARBMAN
Authorized Official - Last Name:MARTIROSYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-997-5304
Mailing Address - Street 1:842 HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-2749
Mailing Address - Country:US
Mailing Address - Phone:847-997-5304
Mailing Address - Fax:
Practice Address - Street 1:842 HOLMES AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-2749
Practice Address - Country:US
Practice Address - Phone:847-997-5304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009820208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty