Provider Demographics
NPI:1245500115
Name:BODY RECOVERY CLINIC
Entity type:Organization
Organization Name:BODY RECOVERY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:928-451-2588
Mailing Address - Street 1:707 E MINGUS AVE STE 504
Mailing Address - Street 2:BODY RECOVERY CLINIC
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-6707
Mailing Address - Country:US
Mailing Address - Phone:928-451-2588
Mailing Address - Fax:
Practice Address - Street 1:707 E MINGUS AVE STE 504
Practice Address - Street 2:BODY RECOVERY CLINIC
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6707
Practice Address - Country:US
Practice Address - Phone:928-451-2588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-04916261QR0400X
173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173C00000XOther Service ProvidersReflexologistGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty