Healthcare Provider Details

I. General information

NPI: 1326870114
Provider Name (Legal Business Name): BODY SHOP PHYSICAL THERAPY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCE WAY UNIT C
HACKENSACK NJ
07601-6307
US

IV. Provider business mailing address

100 COMMERCE WAY
HACKENSACK NJ
07601-6307
US

V. Phone/Fax

Practice location:
  • Phone: 551-999-3616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. SAMUEL MIN
Title or Position: CO-OWNER, FOUNDER, CEO
Credential: DPT
Phone: 551-999-3616