Provider Demographics
NPI:1831633494
Name:STRUCTURAL INTEGRATIVE BODYWORK
Entity type:Organization
Organization Name:STRUCTURAL INTEGRATIVE BODYWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORETTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-271-1678
Mailing Address - Street 1:400 JASPER DR
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-3429
Mailing Address - Country:US
Mailing Address - Phone:321-271-1678
Mailing Address - Fax:
Practice Address - Street 1:595 N NOVA RD
Practice Address - Street 2:SUITE 115
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-4424
Practice Address - Country:US
Practice Address - Phone:321-271-1678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 20965174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty