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General NPI Number Information
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NPI Number | 1104697945
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Entity Type | Organization
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Legal Business Name | PURE BODYWORK
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Dates
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Enumeration Date | 01/10/2024
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Last Update Date | 01/10/2024
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Provider Practice Location Address
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Address Line | 2905 STANFORD AVE
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5524
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Country | US
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Telephone | 310-396-6800
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11072
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City | MARINA DEL REY
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State | CA
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Zip | 90295-7072
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Country | US
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Telephone | 310-849-7799
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Fax |
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Authorized Official
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Title or Position | PROPRIETOR
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Name | SOUTHIDA HOWARD
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Credential |
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Telephone | 310-396-6800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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