Healthcare Provider Details

I. General information

NPI: 1922202126
Provider Name (Legal Business Name): BACKTOGOLF PERFORMANCE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 STATE HIGHWAY 45
AUSTIN TX
78739-1901
US

IV. Provider business mailing address

11318 ADEN CT
AUSTIN TX
78739-1589
US

V. Phone/Fax

Practice location:
  • Phone: 512-371-7687
  • Fax: 512-371-7601
Mailing address:
  • Phone: 512-371-7687
  • Fax: 512-371-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number1029148
License Number StateTX

VIII. Authorized Official

Name: M. JAY PLATT
Title or Position: PRESIDENT
Credential: P.T.
Phone: 512-371-7687