1477167898 NPI number — BACK IN MOTION CAPE CORAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477167898 NPI number — BACK IN MOTION CAPE CORAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK IN MOTION CAPE CORAL LLC
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:
Provider Other Organization Name Type Code:
6
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:
1477167898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9400 GLADIOLUS DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33908-6698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-223-0484
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2546 HEYDON LN STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE CORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33991-3550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-223-0484
Provider Business Practice Location Address Fax Number:
239-790-0969
Provider Enumeration Date:
09/02/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
LEN
Authorized Official Title or Position:
AUTHORIZED OFFICIAL / OWNER
Authorized Official Telephone Number:
219-669-1670

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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