Provider Demographics
NPI:1487475414
Name:EMBODY CO-OP
Entity type:Organization
Organization Name:EMBODY CO-OP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHON
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:STAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:CMT
Authorized Official - Phone:719-505-5174
Mailing Address - Street 1:2860 S CIRCLE DR STE 250I
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4113
Mailing Address - Country:US
Mailing Address - Phone:719-505-5174
Mailing Address - Fax:
Practice Address - Street 1:2860 S CIRCLE DR STE 250I
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4113
Practice Address - Country:US
Practice Address - Phone:719-505-5174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty