Provider Demographics
NPI:1831325406
Name:BOD SQUAD, LLC, THE
Entity type:Organization
Organization Name:BOD SQUAD, LLC, THE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAIVD
Authorized Official - Middle Name:STALLINGS
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:801-400-1834
Mailing Address - Street 1:1803 ABBEDALE LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-3847
Mailing Address - Country:US
Mailing Address - Phone:801-400-1834
Mailing Address - Fax:866-764-1145
Practice Address - Street 1:1803 ABBEDALE LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-3847
Practice Address - Country:US
Practice Address - Phone:801-754-1619
Practice Address - Fax:866-764-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6342141-0144332B00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
03328412405-001OtherBCBS
Q07927Medicare UPIN