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General NPI Number Information
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NPI Number | 1194357293
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Entity Type | Organization
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Legal Business Name | BACK IN MOTION INTEGRATED MEDICINE PLLC
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Dates
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Enumeration Date | 02/06/2020
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Last Update Date | 06/03/2020
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Provider Practice Location Address
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Address Line | 104 GRAPEVINE HWY STE 400
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City | HURST
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State | TX
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Zip | 76054-2438
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Country | US
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Telephone | 817-458-2400
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Fax | 817-485-2475
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Provider Business Mailing Address
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Address Line | PO BOX 1066
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City | COLLEYVILLE
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State | TX
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Zip | 76034-1066
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Country | US
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Telephone | 817-485-2400
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Fax | 817-458-2475
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL ALAN GANSCHOW
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Credential |
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Telephone | 817-764-2291
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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