Provider Demographics
NPI:1578225892
Name:BODY AND SPORT DFW
Entity Type:Organization
Organization Name:BODY AND SPORT DFW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-899-8002
Mailing Address - Street 1:2201 LONG PRAIRIE RD STE 107-845
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4832
Mailing Address - Country:US
Mailing Address - Phone:972-899-8002
Mailing Address - Fax:972-899-8003
Practice Address - Street 1:2601 SAGEBRUSH DR STE 104
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2744
Practice Address - Country:US
Practice Address - Phone:972-899-8002
Practice Address - Fax:972-899-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Single Specialty