Provider Demographics
NPI:1386482149
Name:BACK NINE VENTURES CORP
Entity type:Organization
Organization Name:BACK NINE VENTURES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-261-3171
Mailing Address - Street 1:6236 SCARLET DARTER WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-3209
Mailing Address - Country:US
Mailing Address - Phone:813-261-3171
Mailing Address - Fax:
Practice Address - Street 1:6236 SCARLET DARTER WAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-3209
Practice Address - Country:US
Practice Address - Phone:813-261-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty