Provider Demographics
NPI:1245338946
Name:BACK ON COURSE LLC
Entity type:Organization
Organization Name:BACK ON COURSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PT
Authorized Official - Prefix:MS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLEKY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:203-949-1890
Mailing Address - Street 1:POB 4131
Mailing Address - Street 2:
Mailing Address - City:YALESVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-284-1340
Mailing Address - Fax:203-265-4557
Practice Address - Street 1:29 N PLAINS HWY
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-949-1890
Practice Address - Fax:203-949-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty