Healthcare Provider Details

I. General information

NPI: 1962742098
Provider Name (Legal Business Name): BODY ODYSSEY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 WELTON ST
DENVER CO
80202-4221
US

IV. Provider business mailing address

1616 WELTON ST
DENVER CO
80202-4221
US

V. Phone/Fax

Practice location:
  • Phone: 303-893-2543
  • Fax:
Mailing address:
  • Phone: 303-893-2543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number4222
License Number StateCO

VIII. Authorized Official

Name: MRS. PEGGY LINDY IRVIN
Title or Position: PRESIDENT
Credential: LMT,CBT,APH
Phone: 303-893-2543