Healthcare Provider Details

I. General information

NPI: 1538357173
Provider Name (Legal Business Name): BACK TO THE BEACH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MONTICELLO AVE
NORFOLK VA
23517-2339
US

IV. Provider business mailing address

1900 MONTICELLO AVE
NORFOLK VA
23517-2339
US

V. Phone/Fax

Practice location:
  • Phone: 757-831-9128
  • Fax:
Mailing address:
  • Phone: 757-831-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104556338
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305203689
License Number StateVA

VIII. Authorized Official

Name: DR. ELLIOT DAVID SHERMAN
Title or Position: PRESIDENT
Credential: D.C.
Phone: 757-831-9128