Organization
BACKTOGOLF PERFORMANCE & FITNESS INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY K MULLNIX (PRACTICE ADMINISTRATOR)
(707) 303-4995
Entity
Organization
Contact information
Practice address
208 CONCOURSE BLVD, SANTA ROSA, CA 95403
(707) 303-4992
(707) 303-4996
Mailing address
PO BOX 10, SUITE 2, WINDSOR, CA 95492
(707) 303-4992
(707) 303-4996
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT11380
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
105079200
US DEPT OF LABOR
CA
01
—
DB6552
RAILROAD MEDICARE GRP #
—
01
—
P00120133
RAILROAD MEDICARE (PIN)
—
01
—
ZZZ00793Z
BLUE SHIELD GRP ID
CA
Enumeration date
09/21/2006
Last updated
04/14/2020
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