Provider Demographics
NPI:1366452062
Name:MICHELLE R. CONGLETON, INC.
Entity Type:Organization
Organization Name:MICHELLE R. CONGLETON, INC.
Other - Org Name:THE BODY STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ORAPAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VECHSAMUTVAREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-591-4800
Mailing Address - Street 1:13751 ROSWELL AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5464
Mailing Address - Country:US
Mailing Address - Phone:909-591-4800
Mailing Address - Fax:909-591-6100
Practice Address - Street 1:13751 ROSWELL AVE
Practice Address - Street 2:SUITE G
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5464
Practice Address - Country:US
Practice Address - Phone:909-591-4800
Practice Address - Fax:909-591-6100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02747ZMedicare ID - Type UnspecifiedNORTHERN MEDICARE