Provider Demographics
NPI:1215153747
Name:BODY REHAB CENTER
Entity type:Organization
Organization Name:BODY REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BADT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:310-456-8301
Mailing Address - Street 1:22601 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE250
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-5856
Mailing Address - Country:US
Mailing Address - Phone:310-456-8301
Mailing Address - Fax:310-456-5057
Practice Address - Street 1:5478 WILSHIRE BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4229
Practice Address - Country:US
Practice Address - Phone:323-936-7525
Practice Address - Fax:323-936-7572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT15196Medicare ID - Type Unspecified