Healthcare Provider Details

I. General information

NPI: 1790411445
Provider Name (Legal Business Name): BODY SYNTHESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8439 N LAKE DR APT G
DUBLIN CA
94568-3359
US

IV. Provider business mailing address

8439 N LAKE DR APT G
DUBLIN CA
94568-3359
US

V. Phone/Fax

Practice location:
  • Phone: 818-813-4300
  • Fax:
Mailing address:
  • Phone: 818-813-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TAVARES ALLEN GARRETT
Title or Position: CERTIFIED NUTRITION COACH
Credential: CNC
Phone: 818-813-4300