Healthcare Provider Details

I. General information

NPI: 1295226926
Provider Name (Legal Business Name): ARCHER BODYWORKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 E BROADWAY BLVD STE 114
TUCSON AZ
85711-3575
US

IV. Provider business mailing address

933 N MAIN AVE UNIT 131
TUCSON AZ
85705-7617
US

V. Phone/Fax

Practice location:
  • Phone: 520-304-5330
  • Fax:
Mailing address:
  • Phone: 520-304-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. WILTON I HALL III
Title or Position: MANAGING MEMBER
Credential: MT/BHT
Phone: 520-304-5330