Basic Information
| Provider Information | |||||||||
| NPI: | 1245338946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BACK ON COURSE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | POB 4131 | ||||||||
| Address2: | |||||||||
| City: | YALESVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032841340 | ||||||||
| FaxNumber: | 2032654557 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 N PLAINS HWY | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039491890 | ||||||||
| FaxNumber: | 2039491891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MELLEKY | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER PT | ||||||||
| AuthorizedOfficialTelephone: | 2039491890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.