Basic Information
| Provider Information | |||||||||
| NPI: | 1003940289 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BODYWISE THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27015 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681270015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023939459 | ||||||||
| FaxNumber: | 4023979895 | ||||||||
| Practice Location | |||||||||
| Address1: | 2504 S 119TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681442947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029328686 | ||||||||
| FaxNumber: | 4029328677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4029328686 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 257 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0722173 | 05 | IA | MEDICAID | 02013 | 01 | NE | BCBS OF NE | OTHER |