1104152925 NPI number — BODY DYNAMIC PHYSICAL THERAPY & PILATES WELLNESS

Table of content: (NPI 1104152925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104152925 NPI number — BODY DYNAMIC PHYSICAL THERAPY & PILATES WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BODY DYNAMIC PHYSICAL THERAPY & PILATES WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BODY DYNAMIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104152925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1282 WHITE OAKS RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMPBELL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-550-6076
Provider Business Mailing Address Fax Number:
408-608-1970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1282 WHITE OAKS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMPBELL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-550-6076
Provider Business Practice Location Address Fax Number:
408-608-1970
Provider Enumeration Date:
10/29/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MASTRODICASA
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PHYSICAL THERAPIST/TREASURER
Authorized Official Telephone Number:
408-550-6076

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  24763 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)