Provider Demographics
NPI:1780826396
Name:BODYLOGICMD OF ENCINO P.C.
Entity Type:Organization
Organization Name:BODYLOGICMD OF ENCINO P.C.
Other - Org Name:BODYLOGICMD OF ENCINO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-835-1536
Mailing Address - Street 1:27023 MCBEAN PKWY
Mailing Address - Street 2:83
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-5145
Mailing Address - Country:US
Mailing Address - Phone:877-835-1536
Mailing Address - Fax:877-835-1537
Practice Address - Street 1:16260 VENTURA BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2203
Practice Address - Country:US
Practice Address - Phone:877-835-1536
Practice Address - Fax:877-835-1537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69979174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty