Provider Demographics
NPI:1306242417
Name:PHOENIXBODY WORKS
Entity type:Organization
Organization Name:PHOENIXBODY WORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMP
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DIANA
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA00020960
Authorized Official - Phone:253-880-7447
Mailing Address - Street 1:12815 CANYON RD E STE I
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5104
Mailing Address - Country:US
Mailing Address - Phone:253-880-7447
Mailing Address - Fax:
Practice Address - Street 1:12815 CANYON RD E STE I
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5104
Practice Address - Country:US
Practice Address - Phone:253-880-7447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020960172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty