Provider Demographics
NPI:1366787145
Name:BACK ON TRACK PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:BACK ON TRACK PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-766-1991
Mailing Address - Street 1:9 BEECHNUT CT
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-4710
Mailing Address - Country:US
Mailing Address - Phone:631-766-1991
Mailing Address - Fax:631-728-7029
Practice Address - Street 1:472 MONTAUK HWY
Practice Address - Street 2:UNIT #2
Practice Address - City:EAST QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11942-3930
Practice Address - Country:US
Practice Address - Phone:631-766-1991
Practice Address - Fax:631-728-7029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020636261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy