Provider Demographics
NPI:1790432680
Name:BODY AND SOUL SOVEREIGNTY UNITED
Entity Type:Organization
Organization Name:BODY AND SOUL SOVEREIGNTY UNITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LUANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, CNM, CCTP
Authorized Official - Phone:833-842-5577
Mailing Address - Street 1:20655 W LEGEND TRL
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-1756
Mailing Address - Country:US
Mailing Address - Phone:833-842-5577
Mailing Address - Fax:833-842-5577
Practice Address - Street 1:20655 W LEGEND TRL
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-1756
Practice Address - Country:US
Practice Address - Phone:833-842-5577
Practice Address - Fax:833-842-5577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ481737Medicaid