1780900118 NPI number — EXQUISITE BODY CLINIC

Table of content: (NPI 1780900118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780900118 NPI number — EXQUISITE BODY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXQUISITE BODY CLINIC
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:
Provider Other Organization Name Type Code:
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:
1780900118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3863 SOUTH FWY
Provider Second Line Business Mailing Address:
SUITE 118
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76110-5656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-921-5088
Provider Business Mailing Address Fax Number:
817-921-5087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3863 SOUTH FWY
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76110-5656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-921-5088
Provider Business Practice Location Address Fax Number:
817-921-5087
Provider Enumeration Date:
04/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SMALLHORNE
Authorized Official First Name:
CLEMMIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
817-921-5088

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MT002346 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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