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General NPI Number Information
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NPI Number | 1184746984
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Entity Type | Organization
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Legal Business Name | BACK TO HEALTH CLINIC SC
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 511 N BRUSH COLLEGE RD
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City | DECATUR
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State | IL
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Zip | 62521-1652
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Country | US
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Telephone | 217-233-0650
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Fax | 217-233-5082
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Provider Business Mailing Address
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Address Line | 511 N BRUSH COLLEGE RD
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City | DECATUR
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State | IL
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Zip | 62521-1652
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Country | US
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Telephone | 217-233-0650
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Fax | 217-233-5082
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEITH LEWIS FABRIQUE
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Credential | MD
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Telephone | 217-233-0650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State | IL
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