Provider Demographics
NPI:1912593237
Name:BODY PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:BODY PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:CLAYBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:310-405-1945
Mailing Address - Street 1:822 S ROBERTSON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1633
Mailing Address - Country:US
Mailing Address - Phone:310-405-1945
Mailing Address - Fax:
Practice Address - Street 1:822 S ROBERTSON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1633
Practice Address - Country:US
Practice Address - Phone:310-405-1945
Practice Address - Fax:424-335-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1962952333Medicaid