Provider Demographics
NPI:1548487671
Name:BACK TO LIFE WELLNESS CENTER, INC.
Entity type:Organization
Organization Name:BACK TO LIFE WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARLENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCRUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-280-9730
Mailing Address - Street 1:54 FOUNTAINVEW DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3049
Mailing Address - Country:US
Mailing Address - Phone:314-280-9730
Mailing Address - Fax:
Practice Address - Street 1:2331 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2908
Practice Address - Country:US
Practice Address - Phone:314-280-9730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy