Healthcare Provider Details

I. General information

NPI: 1669774014
Provider Name (Legal Business Name): BODY REFORM PHYSICAL THERAPIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9665 WILSHIRE BLVD #222
BEVERLY HILLS CA
90212-2340
US

IV. Provider business mailing address

9665 WILSHIRE BLVD #222
BEVERLY HILLS CA
90212-2340
US

V. Phone/Fax

Practice location:
  • Phone: 310-247-8414
  • Fax: 310-247-9414
Mailing address:
  • Phone: 310-247-8414
  • Fax: 310-247-9414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT24206
License Number StateCA

VIII. Authorized Official

Name: MARY P. HARRIS
Title or Position: CO-OWNER
Credential:
Phone: 310-247-8414