Provider Demographics
NPI:1134398332
Name:BODY 101
Entity type:Organization
Organization Name:BODY 101
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RADE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-399-0040
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91017-0486
Mailing Address - Country:US
Mailing Address - Phone:909-399-0040
Mailing Address - Fax:
Practice Address - Street 1:1822A E ROUTE 66 # 279
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-3868
Practice Address - Country:US
Practice Address - Phone:909-399-0040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty