Provider Demographics
NPI:1912386376
Name:BODY DYNAMIX INTEGRATED SPORTS MEDICINE, INC
Entity Type:Organization
Organization Name:BODY DYNAMIX INTEGRATED SPORTS MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAIGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-706-9435
Mailing Address - Street 1:18344 OXNARD STREET
Mailing Address - Street 2:UNIT 104
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-783-4085
Mailing Address - Fax:818-783-4065
Practice Address - Street 1:18344 OXNARD STREET
Practice Address - Street 2:UNIT 104
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-783-4085
Practice Address - Fax:818-783-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111NR0400X
CA208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty