Provider Demographics
NPI:1134582018
Name:BACKROAD HEALTH CARE INC
Entity type:Organization
Organization Name:BACKROAD HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAVRILKA
Authorized Official - Suffix:III
Authorized Official - Credentials:FNP
Authorized Official - Phone:618-419-0011
Mailing Address - Street 1:314 S POPLAR ST UNIT 864
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-0848
Mailing Address - Country:US
Mailing Address - Phone:618-419-0011
Mailing Address - Fax:888-960-2931
Practice Address - Street 1:211 S PERRINE AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3635
Practice Address - Country:US
Practice Address - Phone:618-419-0011
Practice Address - Fax:888-980-2931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty