Provider Demographics
NPI:1750153300
Name:BODYWORK REVIVE LIFE SPA
Entity type:Organization
Organization Name:BODYWORK REVIVE LIFE SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLAMON
Authorized Official - Suffix:
Authorized Official - Credentials:MMP
Authorized Official - Phone:325-370-9222
Mailing Address - Street 1:2901 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 S 1ST ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-1813
Practice Address - Country:US
Practice Address - Phone:325-660-6926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty