Provider Demographics
NPI:1700192689
Name:BACK ON TRACK PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:BACK ON TRACK PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MPT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-726-5392
Mailing Address - Street 1:9080 WOODSTORK CT
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-7614
Mailing Address - Country:US
Mailing Address - Phone:941-412-4465
Mailing Address - Fax:
Practice Address - Street 1:9080 WOODSTORK CT
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-7614
Practice Address - Country:US
Practice Address - Phone:941-412-4465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22716261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106980Medicare Oscar/Certification