=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023539210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK TO LIFE PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 329 BRYANT ST STE 2A
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94107-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-538-7878
-----------------------------------------------------
Fax | 415-538-7818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 BRYANT ST STE 2A
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94107-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-538-7878
-----------------------------------------------------
Fax | 415-538-7818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | COLLEENA SEIN-COLON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-538-7878
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------