MEDICARE: BACK TO LIFE WELLNESS CENTER, INC.

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	261QP2000X	Physical Therapy Clinic/Center		MO

General Provider Information

NPI Number	:	1548487671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO LIFE WELLNESS CENTER, INC.

Provider Business Mailing Address
First Line	:	54 FOUNTAINVEW DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3049
Country	:	US
Telephone Number	:	314-280-9730
Fax Number	:

Provider Business Practice Location Address
First Line	:	2331 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2908
Country	:	US
Telephone Number	:	314-280-9730
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHARLENE D SCRUGGS
Credential	:
Telephone Number	:	314-280-9730

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	08/22/2020

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