Healthcare Provider Details

I. General information

NPI: 1386138642
Provider Name (Legal Business Name): BACK IN MOTION P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 KINGSLEY LAKE DR STE 901
ST AUGUSTINE FL
32092-3048
US

IV. Provider business mailing address

225 HOPKINS ST APT A
NEPTUNE BEACH FL
32266-4890
US

V. Phone/Fax

Practice location:
  • Phone: 904-514-4483
  • Fax: 904-325-9049
Mailing address:
  • Phone: 904-514-4483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH11232
License Number StateFL

VIII. Authorized Official

Name: DR. COLBY CALTRIDER
Title or Position: OWNER
Credential: DC
Phone: 904-514-4483