1215095385 NPI number — BACK TO LIFE WELLNESS & REHABILITATION

Table of content: (NPI 1215095385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215095385 NPI number — BACK TO LIFE WELLNESS & REHABILITATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
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Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BACK TO LIFE PHYSICAL THERAPY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215095385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 MARLTON PIKE E
Provider Second Line Business Mailing Address:
SUITE E27
Provider Business Mailing Address City Name:
CHERRY HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08003-2150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-424-6677
Provider Business Mailing Address Fax Number:
856-489-1803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 MARLTON PIKE E
Provider Second Line Business Practice Location Address:
SUITE E27
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08003-2150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-424-6677
Provider Business Practice Location Address Fax Number:
856-489-1803
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCDONOUGH
Authorized Official First Name:
MEGHAN
Authorized Official Middle Name:
RENDFREY
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
856-424-6677

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  QA01105600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2356263000 . This is a "IND BCBS PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2356263000 . This is a "AMERIHEALTH ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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