Healthcare Provider Details

I. General information

NPI: 1457003238
Provider Name (Legal Business Name): BACK TO SELF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2022
Last Update Date: 01/22/2022
Certification Date: 01/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 LUISA ST STE 21
SANTA FE NM
87505-4177
US

IV. Provider business mailing address

1300 LUISA ST STE 21
SANTA FE NM
87505-4177
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-6063
  • Fax:
Mailing address:
  • Phone: 505-603-6063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TEO CLAIRMONT BIELE
Title or Position: LICENSED MASSAGE THERAPIST/OWNER
Credential: LMT
Phone: 505-603-6063