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General NPI Number Information
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NPI Number | 1669571188
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Entity Type | Organization
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Legal Business Name | BACKTOGOLF PERFORMANCE & FITNESS INC
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 04/14/2020
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Provider Practice Location Address
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Address Line | 208 CONCOURSE BLVD
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City | SANTA ROSA
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State | CA
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Zip | 95403
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Country | US
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Telephone | 707-303-4992
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Fax | 707-303-4996
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Provider Business Mailing Address
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Address Line | PO BOX 10 SUITE 2
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City | WINDSOR
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State | CA
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Zip | 95492
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Country | US
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Telephone | 707-303-4992
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Fax | 707-303-4996
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MARY K MULLNIX
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Credential |
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Telephone | 707-303-4995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT11380
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License Number State | CA
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