MEDICARE: BODY OF BEVERLY HILLS WELLNESS INC

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	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1275307662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY OF BEVERLY HILLS WELLNESS INC

Provider Business Mailing Address
First Line	:	17609 VENTURA BLVD STE 104
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-5148
Country	:	US
Telephone Number	:	818-291-3636
Fax Number	:	877-395-9650

Provider Business Practice Location Address
First Line	:	17609 VENTURA BLVD STE 104
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-5148
Country	:	US
Telephone Number	:	818-291-3636
Fax Number	:	877-395-9650

Authorized Official
Title or Position	:	CEO
Name	:	HEIDI REGENASS
Credential	:	MD
Telephone Number	:	818-291-3636

Provider Enumeration Date	:	11/07/2023
Last Update Date	:	11/07/2023

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