Provider Demographics
NPI:1619145331
Name:BODY DYNAMIX CHIROPRACTIC AND PERFORMANCE
Entity Type:Organization
Organization Name:BODY DYNAMIX CHIROPRACTIC AND PERFORMANCE
Other - Org Name:BODY DYNAMIX
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BEAU
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CSCS
Authorized Official - Phone:818-783-4085
Mailing Address - Street 1:17609 VENTURA BLVD STE. LL07
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5134
Mailing Address - Country:US
Mailing Address - Phone:818-783-4085
Mailing Address - Fax:818-783-4065
Practice Address - Street 1:17609 VENTURA BLVD STE. LL07
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5134
Practice Address - Country:US
Practice Address - Phone:818-783-4085
Practice Address - Fax:818-783-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty