Provider Demographics
NPI:1972821874
Name:THE BACK PROGRAM
Entity Type:Organization
Organization Name:THE BACK PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-451-8254
Mailing Address - Street 1:1414 SO OAK AVE
Mailing Address - Street 2:SUITE 2 OWATONNA PHYSICAL THERAPY CENTER INC
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3957
Mailing Address - Country:US
Mailing Address - Phone:507-451-8254
Mailing Address - Fax:507-451-7324
Practice Address - Street 1:1414 SO OAK AVE
Practice Address - Street 2:STE 2 OWATONNA PHYSICAL THERAPY CENTER INC
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3957
Practice Address - Country:US
Practice Address - Phone:507-451-8254
Practice Address - Fax:507-451-7324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty