Provider Demographics
NPI:1194357293
Name:BACK IN MOTION INTEGRATED MEDICINE PLLC
Entity type:Organization
Organization Name:BACK IN MOTION INTEGRATED MEDICINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GANSCHOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-764-2291
Mailing Address - Street 1:PO BOX 1066
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-1066
Mailing Address - Country:US
Mailing Address - Phone:817-485-2400
Mailing Address - Fax:817-458-2475
Practice Address - Street 1:104 GRAPEVINE HWY STE 400
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2438
Practice Address - Country:US
Practice Address - Phone:817-458-2400
Practice Address - Fax:817-485-2475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-06
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty