Healthcare Provider Details

I. General information

NPI: 1780863969
Provider Name (Legal Business Name): BODYWISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3313 W MCGRAW ST
SEATTLE WA
98199-3209
US

IV. Provider business mailing address

3313 W MCGRAW ST
SEATTLE WA
98199-3209
US

V. Phone/Fax

Practice location:
  • Phone: 206-352-7205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMA00022659
License Number StateWA

VIII. Authorized Official

Name: SUSAN CHACE
Title or Position: OWNER
Credential:
Phone: 206-352-7205