=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720692023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK IN MOTION PT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2020
-----------------------------------------------------
Last Update Date | 09/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4445 W 16TH AVE STE 250-A
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-7189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-646-8256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4445 W 16TH AVE STE 250-A
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-7189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-646-8256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. RAFAEL OTANO
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 305-646-8256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------