Provider Demographics
NPI:1194915462
Name:BACK TO ACTION PHYSICAL THERAPY CENTER LLC
Entity type:Organization
Organization Name:BACK TO ACTION PHYSICAL THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIRBS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:764-665-1626
Mailing Address - Street 1:3921 JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-1823
Mailing Address - Country:US
Mailing Address - Phone:734-665-1626
Mailing Address - Fax:734-665-2414
Practice Address - Street 1:3921 JACKSON RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-1823
Practice Address - Country:US
Practice Address - Phone:734-665-1626
Practice Address - Fax:734-665-2414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP47120Medicare PIN