Basic Information
| Provider Information | |||||||||
| NPI: | 1003090705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BODYWISE PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | MINDEN | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894230280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757837606 | ||||||||
| FaxNumber: | 7757837605 | ||||||||
| Practice Location | |||||||||
| Address1: | 1667 LUCERNE ST STE B | ||||||||
| Address2: | |||||||||
| City: | MINDEN | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894234360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757837606 | ||||||||
| FaxNumber: | 7757837605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAVILAND | ||||||||
| AuthorizedOfficialFirstName: | MONIQUE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7757837606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.S.P.T. | ||||||||
| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1784 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100508043 | 05 | NV | MEDICAID |