Provider Demographics
NPI:1710752191
Name:HOLOGRAPHIC BODY LLC
Entity Type:Organization
Organization Name:HOLOGRAPHIC BODY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-954-7091
Mailing Address - Street 1:3834 NE SIMPSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-7961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3014 NE KILLINGSWORTH
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211
Practice Address - Country:US
Practice Address - Phone:541-954-7091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1356065692OtherNPI