=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629057930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODYCENTRAL PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2006
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3124 N SWAN RD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-325-4002
-----------------------------------------------------
Fax | 520-325-4227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3124 N SWAN RD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-325-4002
-----------------------------------------------------
Fax | 520-325-4227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BOBBY ISMAIL
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 209-353-1988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------