MEDICARE: BACK TO LIFE, INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	BH2772	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497937767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO LIFE, INCORPORATED

Provider Business Mailing Address
First Line	:	PO BOX 8237
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85066-8237
Country	:	US
Telephone Number	:	623-594-4870
Fax Number	:	623-444-9213

Provider Business Practice Location Address
First Line	:	5915 W ROANOKE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-1639
Country	:	US
Telephone Number	:	623-594-4870
Fax Number	:	623-444-9213

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. GRACIE PADILLA CONTRERAS
Credential	:
Telephone Number	:	623-594-4870

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	11/29/2007

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Directions to “BACK TO LIFE, INCORPORATED ” Practice Location

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