Healthcare Provider Details

I. General information

NPI: 1396130894
Provider Name (Legal Business Name): BODY ESSENTIAL PHYSICAL THERAPY AND MASSAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 SE LANE AVE
ROSEBURG OR
97470-3956
US

IV. Provider business mailing address

428 OAKVIEW DR
ROSEBURG OR
97471-9519
US

V. Phone/Fax

Practice location:
  • Phone: 541-784-7771
  • Fax: 541-672-1466
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13630
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03533
License Number StateOR

VIII. Authorized Official

Name: JENNIFER HAWKS
Title or Position: SOLE PROPRIETOR OWNER AND STAFF
Credential:
Phone: 541-784-7771