Provider Demographics
NPI: | 1497522478 |
---|---|
Name: | M4L BODY DYNAMICS, LLC |
Entity Type: | Organization |
Organization Name: | M4L BODY DYNAMICS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KELLY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SANDERS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PT |
Authorized Official - Phone: | 805-250-1416 |
Mailing Address - Street 1: | 408 HIGUERA ST STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN LUIS OBISPO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 93401-6135 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 805-788-0805 |
Mailing Address - Fax: | 805-788-0845 |
Practice Address - Street 1: | 410 S MAPLE AVE STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | FALLS CHURCH |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22046-4246 |
Practice Address - Country: | US |
Practice Address - Phone: | 703-988-6010 |
Practice Address - Fax: | 703-526-0438 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-12-08 |
Last Update Date: | 2023-12-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Single Specialty |