Provider Demographics
NPI:1083879464
Name:NORTH RIVER BODY THERAPIES
Entity Type:Organization
Organization Name:NORTH RIVER BODY THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DEITRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:941-721-4559
Mailing Address - Street 1:905 25TH DR E
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-2053
Mailing Address - Country:US
Mailing Address - Phone:941-721-4559
Mailing Address - Fax:941-721-0142
Practice Address - Street 1:905 25TH DR E
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-2053
Practice Address - Country:US
Practice Address - Phone:941-721-4559
Practice Address - Fax:941-721-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29664225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty