Provider Demographics
NPI:1922296045
Name:BACK-N-ACTION PHYSICAL THERAPY AND REHAB SPECIALISTS
Entity Type:Organization
Organization Name:BACK-N-ACTION PHYSICAL THERAPY AND REHAB SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRIAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-552-2996
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:500 BIRCH ST
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1415
Practice Address - Country:US
Practice Address - Phone:715-762-1515
Practice Address - Fax:715-762-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3939-024225100000X
WI37-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG7876OtherRAILROAD MEDICARE
WI36191000Medicaid
6350880001Medicare NSC
DG7876OtherRAILROAD MEDICARE