1629571211 NPI number — BACK 2 HEALTH LLC

Table of content: (NPI 1629571211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629571211 NPI number — BACK 2 HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK 2 HEALTH 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:
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:
1629571211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
819 FOREST PKWY STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30297-2281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-919-1333
Provider Business Mailing Address Fax Number:
404-500-3381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
819 FOREST PKWY STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30297-2281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-919-1333
Provider Business Practice Location Address Fax Number:
404-500-3381
Provider Enumeration Date:
03/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MERRICKS
Authorized Official First Name:
BERNADETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-919-1333

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  CHIR007062 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 856208049A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com