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General NPI Number Information
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NPI Number | 1265854913
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Entity Type | Organization
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Legal Business Name | BODY WORKS PHYSICAL THERAPY & WELLNESS, LLC
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Dates
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Enumeration Date | 01/15/2014
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Last Update Date | 04/24/2014
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Provider Practice Location Address
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Address Line | 100S 2ND STREET
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City | THOMAS
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State | OK
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Zip | 73669-8201
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Country | US
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Telephone | 580-661-2639
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Fax | 580-661-2640
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Provider Business Mailing Address
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Address Line | 100S 2ND STREET
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City | THOMAS
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State | OK
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Zip | 73669-8201
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Country | US
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Telephone | 580-661-2639
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Fax | 580-661-2640
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Authorized Official
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Title or Position | P.T./OWNER
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Name | CHANDA JACKSON
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Credential | P.T.
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Telephone | 580-661-2639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 3728
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License Number State | OK
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