Provider Demographics
NPI:1912362245
Name:BACK IN STEP
Entity Type:Organization
Organization Name:BACK IN STEP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-850-2898
Mailing Address - Street 1:2820 W CHARLESTON BLVD STE 32
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1934
Mailing Address - Country:US
Mailing Address - Phone:702-850-2898
Mailing Address - Fax:702-850-2836
Practice Address - Street 1:2820 W CHARLESTON BLVD STE 32
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1934
Practice Address - Country:US
Practice Address - Phone:702-850-2898
Practice Address - Fax:702-850-2836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20151659970335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier