Healthcare Provider Details

I. General information

NPI: 1477858884
Provider Name (Legal Business Name): THE BODY BUILDER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 WALNUT STREET
COFFEYVILLE KS
67337-5921
US

IV. Provider business mailing address

1121 WALNUT STREET
COFFEYVILLE KS
67337-5921
US

V. Phone/Fax

Practice location:
  • Phone: 620-688-6555
  • Fax: 620-251-3148
Mailing address:
  • Phone: 620-688-6555
  • Fax: 620-251-3148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY JO OVERTON
Title or Position: OWNER
Credential:
Phone: 620-688-6555