Provider Demographics
NPI:1104076413
Name:BACK IN ACTION PHYSICAL THERAPY
Entity type:Organization
Organization Name:BACK IN ACTION PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:PROCACCINI
Authorized Official - Suffix:
Authorized Official - Credentials:PT MS
Authorized Official - Phone:631-941-3295
Mailing Address - Street 1:55 HOPEWELL DR
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2340
Mailing Address - Country:US
Mailing Address - Phone:631-258-9538
Mailing Address - Fax:
Practice Address - Street 1:55 HOPEWELL DR
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2340
Practice Address - Country:US
Practice Address - Phone:631-258-9538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020541-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ12B71OtherMEDICARE PROVIDER