Provider Demographics
NPI:1083157499
Name:BODEN FITNESS SYSTEM LLC
Entity Type:Organization
Organization Name:BODEN FITNESS SYSTEM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:LE
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-508-0779
Mailing Address - Street 1:125 PROSPERITY DR
Mailing Address - Street 2:SUITE 500B
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-5385
Mailing Address - Country:US
Mailing Address - Phone:540-508-0779
Mailing Address - Fax:540-508-0841
Practice Address - Street 1:125 PROSPERITY DR
Practice Address - Street 2:SUITE 500B
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-5385
Practice Address - Country:US
Practice Address - Phone:540-508-0779
Practice Address - Fax:540-508-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256096305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV748AOtherMEDICARE PTAN