Provider Demographics
NPI:1669571188
Name:BACKTOGOLF PERFORMANCE & FITNESS INC
Entity type:Organization
Organization Name:BACKTOGOLF PERFORMANCE & FITNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MULLNIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-303-4995
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492
Mailing Address - Country:US
Mailing Address - Phone:707-303-4992
Mailing Address - Fax:707-303-4996
Practice Address - Street 1:208 CONCOURSE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-303-4992
Practice Address - Fax:707-303-4996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB6552OtherRAILROAD MEDICARE GRP #
CAZZZ00793ZOtherBLUE SHIELD GRP ID
P00120133OtherRAILROAD MEDICARE (PIN)
CA105079200OtherUS DEPT OF LABOR
P00120133OtherRAILROAD MEDICARE (PIN)
CAZZZ00793ZOtherBLUE SHIELD GRP ID