Provider Demographics
NPI:1598339905
Name:ROAD BACK LLC
Entity Type:Organization
Organization Name:ROAD BACK LLC
Other - Org Name:THE ROAD BACK TO WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:GARN
Authorized Official - Last Name:RODEBACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-414-9858
Mailing Address - Street 1:1818 MUELLER PARK RD
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1105
Mailing Address - Country:US
Mailing Address - Phone:435-414-9858
Mailing Address - Fax:
Practice Address - Street 1:1818 MUELLER PARK RD
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-1105
Practice Address - Country:US
Practice Address - Phone:435-414-9858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty