Provider Demographics
NPI:1790563393
Name:INTERCONNECT BODYWORKS LLC
Entity type:Organization
Organization Name:INTERCONNECT BODYWORKS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOO
Authorized Official - Middle Name:
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CLT
Authorized Official - Phone:971-238-8756
Mailing Address - Street 1:10445 SW CANYON RD STE 111C
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1938
Mailing Address - Country:US
Mailing Address - Phone:971-238-8756
Mailing Address - Fax:888-860-7014
Practice Address - Street 1:10445 SW CANYON RD STE 111C
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1938
Practice Address - Country:US
Practice Address - Phone:971-238-8756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-15
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty