Provider Demographics
NPI:1710278338
Name:THERAPEUTIC BODY SHOPPE, LLC
Entity Type:Organization
Organization Name:THERAPEUTIC BODY SHOPPE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JODY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:231-747-9163
Mailing Address - Street 1:765 W NORTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4750
Mailing Address - Country:US
Mailing Address - Phone:231-747-9163
Mailing Address - Fax:888-224-6798
Practice Address - Street 1:765 W NORTON AVE
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-4750
Practice Address - Country:US
Practice Address - Phone:231-747-9163
Practice Address - Fax:888-224-6798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000434172M00000X, 225700000X, 172M00000X, 225700000X
MI5101008524171100000X
2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI140709086OtherNPPES