Provider Demographics
NPI:1780954693
Name:BACK2LIFE
Entity type:Organization
Organization Name:BACK2LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:619-271-5166
Mailing Address - Street 1:17530 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3818
Mailing Address - Country:US
Mailing Address - Phone:818-300-0025
Mailing Address - Fax:888-853-4631
Practice Address - Street 1:835 3RD AVE
Practice Address - Street 2:SUITE A-2
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-271-5166
Practice Address - Fax:888-853-4631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization