Healthcare Provider Details

I. General information

NPI: 1043879018
Provider Name (Legal Business Name): BACK2ACTIVITY PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N HOBART ST
PAMPA TX
79065-4126
US

IV. Provider business mailing address

1814 CHARLES ST
PAMPA TX
79065-3610
US

V. Phone/Fax

Practice location:
  • Phone: 806-419-1168
  • Fax: 806-419-1149
Mailing address:
  • Phone: 806-419-1168
  • Fax: 806-419-1169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLEA MOORE
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: MPT
Phone: 806-663-2602