Healthcare Provider Details

I. General information

NPI: 1245500115
Provider Name (Legal Business Name): BODY RECOVERY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MINGUS AVE STE 504 BODY RECOVERY CLINIC
COTTONWOOD AZ
86326-6707
US

IV. Provider business mailing address

707 E MINGUS AVE STE 504 BODY RECOVERY CLINIC
COTTONWOOD AZ
86326-6707
US

V. Phone/Fax

Practice location:
  • Phone: 928-451-2588
  • Fax:
Mailing address:
  • Phone: 928-451-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberMT-04916
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROBERTA D RUSSELL
Title or Position: OWNER
Credential: LMT
Phone: 928-451-2588