Provider Demographics
NPI:1679024228
Name:360 BODY WELLNESS INC
Entity Type:Organization
Organization Name:360 BODY WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:S
Authorized Official - Last Name:DUDAK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:314-753-2233
Mailing Address - Street 1:3407 IL STATE ROUTE 157
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034
Mailing Address - Country:US
Mailing Address - Phone:618-288-3610
Mailing Address - Fax:
Practice Address - Street 1:3407 IL STATE ROUTE 157
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-288-3610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty