Provider Demographics
NPI:1144057555
Name:BODYSHOP PROFESSIONAL MASSAGE THERAPY
Entity type:Organization
Organization Name:BODYSHOP PROFESSIONAL MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTIONETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MEREDITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:630-418-4440
Mailing Address - Street 1:500 COVENTRY LN STE 130
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7578
Mailing Address - Country:US
Mailing Address - Phone:630-446-0110
Mailing Address - Fax:
Practice Address - Street 1:500 COVENTRY LN STE 130
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7578
Practice Address - Country:US
Practice Address - Phone:630-446-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Single Specialty