Healthcare Provider Details

I. General information

NPI: 1467857086
Provider Name (Legal Business Name): BACKROAD HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7825A EAST GRANT ROAD
WALNUT HILL IL
62893
US

IV. Provider business mailing address

7825A EAST GRANT ROAD
WALNUT HILL IL
62893
US

V. Phone/Fax

Practice location:
  • Phone: 618-545-0707
  • Fax:
Mailing address:
  • Phone: 618-545-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209010715
License Number StateIL

VIII. Authorized Official

Name: PAUL HAVRILKA
Title or Position: OWNER/PROVIDER
Credential: APN, FNP-C
Phone: 618-545-0707