Provider Demographics
NPI:1891160552
Name:COLLEYVILLE BODY FOCUS WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:COLLEYVILLE BODY FOCUS WELLNESS CLINIC, LLC
Other - Org Name:JUVIA MED SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-792-5700
Mailing Address - Street 1:9101 LBJ FWY
Mailing Address - Street 2:STE 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-2057
Mailing Address - Country:US
Mailing Address - Phone:972-792-5700
Mailing Address - Fax:
Practice Address - Street 1:4620 COLLEYVILLE BLVD
Practice Address - Street 2:STE 102
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-3971
Practice Address - Country:US
Practice Address - Phone:817-427-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5550207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN5550OtherTMB