Provider Demographics
NPI:1598819468
Name:BODYWORX PHYSICAL THERAPY & CHIROPRACTIC WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:BODYWORX PHYSICAL THERAPY & CHIROPRACTIC WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PROFITT
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CSCS, DC
Authorized Official - Phone:606-836-6683
Mailing Address - Street 1:1451 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1718
Mailing Address - Country:US
Mailing Address - Phone:606-836-6683
Mailing Address - Fax:
Practice Address - Street 1:1451 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1718
Practice Address - Country:US
Practice Address - Phone:606-833-2173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4634111N00000X
KY005907225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1188596OtherCHA PROVIDER NUMBER
KY85900272Medicaid
KY85001501Medicaid
KY350054419Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KY1188596OtherCHA PROVIDER NUMBER
KY7138Medicare ID - Type UnspecifiedMEDICARE GROUP
KYU81659Medicare UPIN