=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932248754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK IN MOTION REHABILITATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 10/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2618 CENTER AVE
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48708-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-892-4557
-----------------------------------------------------
Fax | 989-892-4686
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 N WATER ST
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48708-5620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-450-3341
-----------------------------------------------------
Fax | 989-778-1237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, OPERATIONS
-----------------------------------------------------
Name | LYNDSY MCROBERTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 989-450-3341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501003708
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501008385
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------