Provider Demographics
NPI:1265854913
Name:BODY WORKS PHYSICAL THERAPY & WELLNESS, LLC
Entity type:Organization
Organization Name:BODY WORKS PHYSICAL THERAPY & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.T./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:580-661-2639
Mailing Address - Street 1:100S 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:OK
Mailing Address - Zip Code:73669-8201
Mailing Address - Country:US
Mailing Address - Phone:580-661-2639
Mailing Address - Fax:580-661-2640
Practice Address - Street 1:100S 2ND STREET
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:OK
Practice Address - Zip Code:73669-8201
Practice Address - Country:US
Practice Address - Phone:580-661-2639
Practice Address - Fax:580-661-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3728261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK334696Medicare PIN