Provider Demographics
NPI:1386709178
Name:BACK TO HEALTH MEDICINE AND DIAGNOSTICS
Entity type:Organization
Organization Name:BACK TO HEALTH MEDICINE AND DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:DECESARE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:845-635-5002
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12569-0550
Mailing Address - Country:US
Mailing Address - Phone:845-635-5002
Mailing Address - Fax:845-635-5295
Practice Address - Street 1:1395 ROUTE 44
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569-7830
Practice Address - Country:US
Practice Address - Phone:845-635-5002
Practice Address - Fax:845-635-5295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BACK TO HEALTH MEDICINE AND DIAGNOSTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-22
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008697111N00000X
NYX0068561111N00000X
NY147245207YX0901X
NY014665-1225100000X
NY025281-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEQ771Medicare PIN