Provider Demographics
NPI:1003090705
Name:BODYWISE PHYSICAL THERAPY
Entity type:Organization
Organization Name:BODYWISE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAVILAND
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:775-783-7606
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-0280
Mailing Address - Country:US
Mailing Address - Phone:775-783-7606
Mailing Address - Fax:775-783-7605
Practice Address - Street 1:1667 LUCERNE ST STE B
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-4360
Practice Address - Country:US
Practice Address - Phone:775-783-7606
Practice Address - Fax:775-783-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508043Medicaid
NVP24859Medicare UPIN