Healthcare Provider Details

I. General information

NPI: 1679502132
Provider Name (Legal Business Name): DALE MICHAEL BODMER LMT, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4589 KENNY RD STE 101
COLUMBUS OH
43220-2778
US

IV. Provider business mailing address

3474 CASTLETON ST
GROVE CITY OH
43123-2125
US

V. Phone/Fax

Practice location:
  • Phone: 614-578-7470
  • Fax: 855-578-7470
Mailing address:
  • Phone: 614-578-7470
  • Fax: 855-578-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.008563
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: