Healthcare Provider Details

I. General information

NPI: 1346751484
Provider Name (Legal Business Name): BACK TO NORMAL II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 SADDLE ROWE LN
NORTH SCITUATE RI
02857-1271
US

IV. Provider business mailing address

DEPT # 880237 PO BOX 29650
PHOENIX AZ
85038-9650
US

V. Phone/Fax

Practice location:
  • Phone: 401-749-0539
  • Fax:
Mailing address:
  • Phone: 800-310-7334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License NumberMD12647
License Number StateRI

VIII. Authorized Official

Name: JOHN K CZERWEIN JR.
Title or Position: MANAGER
Credential: MD
Phone: 800-310-7334