Provider Demographics
NPI:1356621395
Name:BACK IN ACTION PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:BACK IN ACTION PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTOFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:907-376-2225
Mailing Address - Street 1:1001 E BOGARD RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7114
Mailing Address - Country:US
Mailing Address - Phone:907-376-2225
Mailing Address - Fax:907-376-9225
Practice Address - Street 1:1001 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7114
Practice Address - Country:US
Practice Address - Phone:907-376-2225
Practice Address - Fax:907-376-9225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINE AND SPORTS INJURY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-23
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1683033Medicaid