MEDICARE: BACK IN MOTION SPECIALTY PRACTICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1235971425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK IN MOTION SPECIALTY PRACTICE LLC

Provider Business Mailing Address
First Line	:	9724 COMMERCE CENTER CT STE B
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-3865
Country	:	US
Telephone Number	:	239-223-0484
Fax Number	:	239-790-0969

Provider Business Practice Location Address
First Line	:	9724 COMMERCE CENTER CT STE B
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-3865
Country	:	US
Telephone Number	:	239-223-0484
Fax Number	:	239-790-0969

Authorized Official
Title or Position	:	OWNER
Name	:	ASHLEY GRAY
Credential	:
Telephone Number	:	239-223-0484

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	06/10/2024

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Directions to “BACK IN MOTION SPECIALTY PRACTICE LLC ” Practice Location

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