Provider Demographics
NPI:1942460811
Name:1 BODY HEALTH AND FITNESS PA
Entity Type:Organization
Organization Name:1 BODY HEALTH AND FITNESS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-253-2111
Mailing Address - Street 1:105 INTERNATIONAL DR
Mailing Address - Street 2:SUITE 121
Mailing Address - City:RED LAKE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56750-4665
Mailing Address - Country:US
Mailing Address - Phone:218-253-2111
Mailing Address - Fax:
Practice Address - Street 1:105 INTERNATIONAL DR
Practice Address - Street 2:SUITE 121
Practice Address - City:RED LAKE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56750-4665
Practice Address - Country:US
Practice Address - Phone:218-253-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4K044THOtherBLUE CROSS
MN822797011671OtherPREFERRED ONE
MN4K044THOtherBLUE CROSS
MN822797011671OtherPREFERRED ONE