Healthcare Provider Details

I. General information

NPI: 1033220470
Provider Name (Legal Business Name): BACK TO LIFE PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 W AARON DR SUITE 201
STATE COLLEGE PA
16803-3074
US

IV. Provider business mailing address

424 W AARON DR SUITE 201
STATE COLLEGE PA
16803-3074
US

V. Phone/Fax

Practice location:
  • Phone: 814-235-9995
  • Fax: 814-235-9616
Mailing address:
  • Phone: 814-235-9995
  • Fax: 814-235-9616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SUSAN PETTENGILL
Title or Position: OFFICE MANAGER
Credential:
Phone: 814-235-9995