Provider Demographics
NPI:1417175415
Name:BODY REFORM PHYSICAL THERAPIES INC.
Entity Type:Organization
Organization Name:BODY REFORM PHYSICAL THERAPIES INC.
Other - Org Name:BODY REFORM
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO, PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:310-247-8414
Mailing Address - Street 1:414 N CAMDEN DR
Mailing Address - Street 2:1050
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4532
Mailing Address - Country:US
Mailing Address - Phone:310-247-8414
Mailing Address - Fax:310-247-9414
Practice Address - Street 1:414 N CAMDEN DR
Practice Address - Street 2:1050
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4532
Practice Address - Country:US
Practice Address - Phone:310-247-8414
Practice Address - Fax:310-247-9414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 24206261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy