Healthcare Provider Details

I. General information

NPI: 1144057555
Provider Name (Legal Business Name): BODYSHOP PROFESSIONAL MASSAGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 COVENTRY LN STE 130
CRYSTAL LAKE IL
60014-7578
US

IV. Provider business mailing address

500 COVENTRY LN STE 130
CRYSTAL LAKE IL
60014-7578
US

V. Phone/Fax

Practice location:
  • Phone: 630-446-0110
  • Fax:
Mailing address:
  • Phone: 630-446-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: ANTIONETTE M MEREDITH
Title or Position: LICENSED MASSAGE THERAPIST
Credential: LMT
Phone: 630-418-4440