Provider Demographics
NPI:1629021290
Name:BODYWISE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:BODYWISE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOSELEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, LMT
Authorized Official - Phone:503-701-4390
Mailing Address - Street 1:1030 NW 12TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2838
Mailing Address - Country:US
Mailing Address - Phone:503-701-4390
Mailing Address - Fax:503-974-2612
Practice Address - Street 1:1030 NW 12TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2838
Practice Address - Country:US
Practice Address - Phone:503-701-4390
Practice Address - Fax:503-974-2612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0829199-3225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR134858Medicare PIN