Provider Demographics
NPI:1215095385
Name:BACK TO LIFE WELLNESS & REHABILITATION
Entity type:Organization
Organization Name:BACK TO LIFE WELLNESS & REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:RENDFREY
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:856-424-6677
Mailing Address - Street 1:1930 MARLTON PIKE E
Mailing Address - Street 2:SUITE E27
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2150
Mailing Address - Country:US
Mailing Address - Phone:856-424-6677
Mailing Address - Fax:856-489-1803
Practice Address - Street 1:1930 MARLTON PIKE E
Practice Address - Street 2:SUITE E27
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2150
Practice Address - Country:US
Practice Address - Phone:856-424-6677
Practice Address - Fax:856-489-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA01105600261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2356263000OtherIND BCBS PERSONAL CHOICE
NJ2356263000OtherAMERIHEALTH ID
NJ2356263000OtherAMERIHEALTH ID