Provider Demographics
NPI:1790468353
Name:302 BODY SHOP
Entity Type:Organization
Organization Name:302 BODY SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:302-331-9026
Mailing Address - Street 1:4601 SOUTH DUPONT HIGHWAY
Mailing Address - Street 2:ST 1
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901
Mailing Address - Country:US
Mailing Address - Phone:302-698-1100
Mailing Address - Fax:
Practice Address - Street 1:4601 SOUTH DUPONT HIGHWAY
Practice Address - Street 2:ST 1
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901
Practice Address - Country:US
Practice Address - Phone:302-698-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center