Provider Demographics
NPI:1992730469
Name:BACK IN MOTION PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:BACK IN MOTION PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:NALLS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:703-690-2650
Mailing Address - Street 1:9447B LORTON MARKET ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1963
Mailing Address - Country:US
Mailing Address - Phone:703-372-5716
Mailing Address - Fax:703-372-5718
Practice Address - Street 1:9447B LORTON MARKET ST
Practice Address - Street 2:SUITE 250
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1963
Practice Address - Country:US
Practice Address - Phone:703-372-5716
Practice Address - Fax:703-372-5718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG00924Medicare ID - Type Unspecified