MEDICARE: WELLBODY THERAPEUTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	979838	OR

General Provider Information

NPI Number	:	1821225103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLBODY THERAPEUTICS, LLC

Provider Business Mailing Address
First Line	:	2195 NE PROFESSIONAL CT
Second Line	:	SUITE # 6
City	:	BEND
State	:	OR
Zip	:	97701-6028
Country	:	US
Telephone Number	:	541-390-4361
Fax Number	:	541-322-9398

Provider Business Practice Location Address
First Line	:	2195 NE PROFESSIONAL CT
Second Line	:	SUITE # 6
City	:	BEND
State	:	OR
Zip	:	97701-6028
Country	:	US
Telephone Number	:	541-390-4361
Fax Number	:	541-322-9398

Authorized Official
Title or Position	:	OWNER, PROVIDER
Name	:	MS. AMY L LAFFERTY
Credential	:	MS, OTR/L
Telephone Number	:	541-390-4361

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	06/15/2009

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