Provider Demographics
NPI:1609941434
Name:BACK TO ACTION PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BACK TO ACTION PHYSICAL THERAPY
Other - Org Name:BACK TO ACTION PHYSICAL THERAPY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:MCKROLA
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:303-665-8747
Mailing Address - Street 1:150 OLD LARAMIE TRL E
Mailing Address - Street 2:STE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7018
Mailing Address - Country:US
Mailing Address - Phone:303-665-8747
Mailing Address - Fax:303-926-0184
Practice Address - Street 1:150 OLD LARAMIE TRL E
Practice Address - Street 2:STE 100
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-7018
Practice Address - Country:US
Practice Address - Phone:303-665-8747
Practice Address - Fax:303-926-0184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCE0003Medicare PIN