Healthcare Provider Details

I. General information

NPI: 1669150298
Provider Name (Legal Business Name): LOOSEN UP BODYWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 OAKLAND BLVD STE 100
WALNUT CREEK CA
94596-4300
US

IV. Provider business mailing address

1407 OAKLAND BLVD STE 100
WALNUT CREEK CA
94596-4300
US

V. Phone/Fax

Practice location:
  • Phone: 925-289-9750
  • Fax:
Mailing address:
  • Phone: 925-289-9750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GINA D TIBBS
Title or Position: OWNER
Credential: CMT
Phone: 925-289-9750