Provider Demographics
NPI:1255503736
Name:LAS VEGAS BODYWORKS LLC
Entity Type:Organization
Organization Name:LAS VEGAS BODYWORKS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:MASAO
Authorized Official - Last Name:NAKASONE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-454-0443
Mailing Address - Street 1:508 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4349
Mailing Address - Country:US
Mailing Address - Phone:505-454-0443
Mailing Address - Fax:505-454-0498
Practice Address - Street 1:508 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4349
Practice Address - Country:US
Practice Address - Phone:505-454-0443
Practice Address - Fax:505-454-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty