=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104076413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK IN ACTION PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2008
-----------------------------------------------------
Last Update Date | 09/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 HOPEWELL DR
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-258-9538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 HOPEWELL DR
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-258-9538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. MICHAEL V PROCACCINI
-----------------------------------------------------
Credential | P.T . M.S.
-----------------------------------------------------
Telephone | 631-941-3295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 020541-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------