Provider Demographics
NPI:1992110647
Name:BODYVANA
Entity type:Organization
Organization Name:BODYVANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GITCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-549-1105
Mailing Address - Street 1:4600 UNION BAY PL NE
Mailing Address - Street 2:STE B
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-4037
Mailing Address - Country:US
Mailing Address - Phone:206-755-4857
Mailing Address - Fax:
Practice Address - Street 1:4600 UNION BAY PL NE
Practice Address - Street 2:STE B
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4037
Practice Address - Country:US
Practice Address - Phone:206-755-4857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60112084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty