Provider Demographics
NPI:1669150298
Name:LOOSEN UP BODYWORK
Entity type:Organization
Organization Name:LOOSEN UP BODYWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:CMT
Authorized Official - Phone:925-289-9750
Mailing Address - Street 1:1407 OAKLAND BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-4300
Mailing Address - Country:US
Mailing Address - Phone:925-289-9750
Mailing Address - Fax:
Practice Address - Street 1:1407 OAKLAND BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4300
Practice Address - Country:US
Practice Address - Phone:925-289-9750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty