Provider Demographics
NPI:1881094621
Name:BACK IN MOTION PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:BACK IN MOTION PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:KAUFENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:218-346-2464
Mailing Address - Street 1:505 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-1808
Mailing Address - Country:US
Mailing Address - Phone:218-346-2464
Mailing Address - Fax:218-346-2446
Practice Address - Street 1:505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1808
Practice Address - Country:US
Practice Address - Phone:218-346-2464
Practice Address - Fax:218-346-2446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1366533861Medicaid
MN6500000359Medicare PIN