Provider Demographics
NPI:1831616416
Name:BACK IN MOTION SPORT & SPINE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:BACK IN MOTION SPORT & SPINE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:239-223-0484
Mailing Address - Street 1:9400 GLADIOLUS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-6698
Mailing Address - Country:US
Mailing Address - Phone:239-223-2484
Mailing Address - Fax:239-790-0969
Practice Address - Street 1:9400 GLADIOLUS DR STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-6698
Practice Address - Country:US
Practice Address - Phone:239-223-0484
Practice Address - Fax:239-790-0969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL307402251S0007X
FLPT30740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty