MEDICARE: STRUCTURA BODY THERAPIES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	7760739-4701	UT

General Provider Information

NPI Number	:	1124401443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STRUCTURA BODY THERAPIES, LLC

Provider Business Mailing Address
First Line	:	6112 S 1550 E
Second Line	:	203
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-5007
Country	:	US
Telephone Number	:	801-897-8711
Fax Number	:	801-475-1795

Provider Business Practice Location Address
First Line	:	6112 S 1550 E
Second Line	:	203
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-5007
Country	:	US
Telephone Number	:	801-897-8711
Fax Number	:	801-475-1795

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. NANCY E. PRINCE
Credential	:	L.M.T, S.I.P
Telephone Number	:	801-888-0103

Provider Enumeration Date	:	07/06/2015
Last Update Date	:	12/16/2019

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