Provider Demographics
NPI:1073900627
Name:FRESNO KINETIC BODYWORKS
Entity Type:Organization
Organization Name:FRESNO KINETIC BODYWORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:CMT
Authorized Official - Phone:559-492-6848
Mailing Address - Street 1:336 W BEDFORD AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-6185
Mailing Address - Country:US
Mailing Address - Phone:559-492-6848
Mailing Address - Fax:
Practice Address - Street 1:336 W BEDFORD AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-6185
Practice Address - Country:US
Practice Address - Phone:559-492-6848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61093225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty