Healthcare Provider Details

I. General information

NPI: 1619852050
Provider Name (Legal Business Name): BODYSHOP ATHLETIC THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 SAN ANTONIO BLVD
DURHAM NC
27703
US

IV. Provider business mailing address

5540 CENTERVIEW DR STE 200
RALEIGH NC
27606-3386
US

V. Phone/Fax

Practice location:
  • Phone: 224-678-4532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW AIELLO
Title or Position: OWNER
Credential:
Phone: 224-678-4532