Healthcare Provider Details

I. General information

NPI: 1023106127
Provider Name (Legal Business Name): BODYWISE STUDIOS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2706 OLD MOULTRIE RD
ST AUGUSTINE FL
32086-5447
US

IV. Provider business mailing address

PO BOX 5538
ST AUGUSTINE FL
32085-5538
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-6760
  • Fax:
Mailing address:
  • Phone: 904-794-6760
  • Fax: 904-794-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT 12766
License Number StateFL

VIII. Authorized Official

Name: MS. SUSAN POLAND HUFFMAN
Title or Position: PRESIDENT
Credential: P.T.
Phone: 904-794-6760