Provider Demographics
NPI:1396887170
Name:BODE, GREG D (LAC, LMT)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:D
Last Name:BODE
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 222221
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33022-2221
Mailing Address - Country:US
Mailing Address - Phone:954-394-0087
Mailing Address - Fax:800-859-8215
Practice Address - Street 1:1940 HARRISON ST
Practice Address - Street 2:STE. 202
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-5082
Practice Address - Country:US
Practice Address - Phone:954-929-9939
Practice Address - Fax:800-859-8215
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001389171100000X
FLAP1602171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist