Provider Demographics
NPI:1831289107
Name:BACK & BODY THERAPEUTIC TOUCH, LLC
Entity Type:Organization
Organization Name:BACK & BODY THERAPEUTIC TOUCH, LLC
Other - Org Name:BACK & BODY REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SWANKE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:920-229-0955
Mailing Address - Street 1:N6681 COUNTY RD N
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WI
Mailing Address - Zip Code:54968-9323
Mailing Address - Country:US
Mailing Address - Phone:920-229-0955
Mailing Address - Fax:
Practice Address - Street 1:147 N STATE ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1621
Practice Address - Country:US
Practice Address - Phone:920-229-0955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI729-026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40729700Medicaid