Healthcare Provider Details

I. General information

NPI: 1417440025
Provider Name (Legal Business Name): BODY ENVI WEIGHT LOSS & WELLNESS II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6904 W LINEBAUGH AVE
TAMPA FL
33625
US

IV. Provider business mailing address

13449 CANOPY CREEK DR
TAMPA FL
33625-5915
US

V. Phone/Fax

Practice location:
  • Phone: 813-888-7710
  • Fax: 813-908-7711
Mailing address:
  • Phone: 813-888-7710
  • Fax: 813-908-7711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY MORERA
Title or Position: CEO
Credential:
Phone: 813-888-7710