Provider Demographics
NPI:1700185741
Name:HEALTHY BODY HEALTHY MIND
Entity Type:Organization
Organization Name:HEALTHY BODY HEALTHY MIND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FOO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-722-8704
Mailing Address - Street 1:1029 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2550
Mailing Address - Country:US
Mailing Address - Phone:847-722-8704
Mailing Address - Fax:847-929-9568
Practice Address - Street 1:1029 W PARK AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2550
Practice Address - Country:US
Practice Address - Phone:847-722-8704
Practice Address - Fax:847-929-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000668171100000X
IL198000516171100000X
IL070013796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty