Healthcare Provider Details

I. General information

NPI: 1497270151
Provider Name (Legal Business Name): 180 BODYWORKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 MAIN ST STE 216
VANCOUVER WA
98663-1888
US

IV. Provider business mailing address

2504 34TH ST
WASHOUGAL WA
98671-9157
US

V. Phone/Fax

Practice location:
  • Phone: 360-609-8343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMA60288718
License Number StateWA

VIII. Authorized Official

Name: MRS. ASHLEY ANNE MERKLIN
Title or Position: OWNER
Credential: LMP
Phone: 360-609-8343