Provider Demographics
NPI:1336366400
Name:BACK IN MOTION SPINAL CLINIC,INC
Entity Type:Organization
Organization Name:BACK IN MOTION SPINAL CLINIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:KALODISH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-748-1004
Mailing Address - Street 1:2704 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-2435
Mailing Address - Country:US
Mailing Address - Phone:954-748-1004
Mailing Address - Fax:
Practice Address - Street 1:2704 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322-2435
Practice Address - Country:US
Practice Address - Phone:954-748-1004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007076111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU67507Medicare UPIN
FL00055379Medicare ID - Type UnspecifiedNUMBER