Provider Demographics
NPI:1548764665
Name:ISLAND BODY WORKS LLC
Entity Type:Organization
Organization Name:ISLAND BODY WORKS LLC
Other - Org Name:THE P.T. CENTER FOR PELVIC DISORDERS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ZIMMER
Authorized Official - Last Name:TRUNZO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:716-773-3300
Mailing Address - Street 1:2423 GRAND ISLAND BLVD.
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2967
Mailing Address - Country:US
Mailing Address - Phone:716-773-3300
Mailing Address - Fax:716-773-3303
Practice Address - Street 1:2423 GRAND ISLAND BLVD.
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-2967
Practice Address - Country:US
Practice Address - Phone:716-773-3300
Practice Address - Fax:716-773-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013305-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04956254Medicaid