Provider Demographics
NPI:1528486982
Name:BODYWORK FOR THE ACTIVE
Entity type:Organization
Organization Name:BODYWORK FOR THE ACTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEAUSTRIA
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMT
Authorized Official - Phone:971-246-0057
Mailing Address - Street 1:2701 NW VAUGHN ST STE 154
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5349
Mailing Address - Country:US
Mailing Address - Phone:971-246-0057
Mailing Address - Fax:
Practice Address - Street 1:2701 NW VAUGHN ST STE 154
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5349
Practice Address - Country:US
Practice Address - Phone:971-246-0057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15490172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty