Provider Demographics
NPI:1922202126
Name:BACKTOGOLF PERFORMANCE CENTER, LLC
Entity Type:Organization
Organization Name:BACKTOGOLF PERFORMANCE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:M.
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PLATT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:512-371-7687
Mailing Address - Street 1:11318 ADEN CT
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78739-1589
Mailing Address - Country:US
Mailing Address - Phone:512-371-7687
Mailing Address - Fax:512-371-7601
Practice Address - Street 1:7401 STATE HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78739-1901
Practice Address - Country:US
Practice Address - Phone:512-371-7687
Practice Address - Fax:512-371-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10291482251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0089GJOtherBCBS GROUP NUMBER