MEDICARE: BACK TO LIFE, 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	BH 3093	AZ

General Provider Information

NPI Number	:	1982871901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO LIFE, INC

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	:

Provider Business Practice Location Address
First Line	:	12613 N 36TH LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-2108
Country	:	US
Telephone Number	:	602-354-4055
Fax Number	:

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

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	05/08/2008

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