Provider Demographics
NPI:1538357173
Name:BACK TO THE BEACH, INC
Entity type:Organization
Organization Name:BACK TO THE BEACH, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-831-9128
Mailing Address - Street 1:1900 MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2339
Mailing Address - Country:US
Mailing Address - Phone:757-831-9128
Mailing Address - Fax:
Practice Address - Street 1:1900 MONTICELLO AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2339
Practice Address - Country:US
Practice Address - Phone:757-831-9128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203689225100000X
VA0104556338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty