Healthcare Provider Details

I. General information

NPI: 1831325406
Provider Name (Legal Business Name): BOD SQUAD, LLC, THE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 ABBEDALE LN
SANDY UT
84092-3847
US

IV. Provider business mailing address

1803 ABBEDALE LN
SANDY UT
84092-3847
US

V. Phone/Fax

Practice location:
  • Phone: 801-754-1619
  • Fax: 866-764-1145
Mailing address:
  • Phone: 801-400-1834
  • Fax: 866-764-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6342141-0144
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6342141-0144
License Number StateUT

VIII. Authorized Official

Name: DAIVD STALLINGS JENSEN
Title or Position: OWNER
Credential: MSPT
Phone: 801-400-1834