Provider Demographics
NPI:1841241411
Name:BODY PHYSICAL THERAPY AND FITNESS INC
Entity Type:Organization
Organization Name:BODY PHYSICAL THERAPY AND FITNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICANOR
Authorized Official - Middle Name:LUMBRE
Authorized Official - Last Name:BOBADILLA
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:818-789-6474
Mailing Address - Street 1:7702 BALBOA BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2244
Mailing Address - Country:US
Mailing Address - Phone:818-789-6474
Mailing Address - Fax:818-789-6467
Practice Address - Street 1:7702 BALBOA BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-2244
Practice Address - Country:US
Practice Address - Phone:818-789-6474
Practice Address - Fax:818-789-6467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ65116ZOtherBLUE SHIELD
CAZZZ65116ZOtherBLUE SHIELD