Provider Demographics
NPI:1053890269
Name:KEYSTONE BODY THERAPIES
Entity type:Organization
Organization Name:KEYSTONE BODY THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TATE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDCASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-686-8647
Mailing Address - Street 1:1600 W CHANDLER BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6162
Mailing Address - Country:US
Mailing Address - Phone:480-686-8647
Mailing Address - Fax:
Practice Address - Street 1:1600 W CHANDLER BLVD STE 250
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6162
Practice Address - Country:US
Practice Address - Phone:480-686-8647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-06814225700000X
AZMT-17566225700000X
AZMT-22972225700000X
AZMT-19729225700000X
AZMT-17560225700000X
AZMT-24282225700000X
AZMT-24731225700000X
AZMT-23770225700000X
AZMT-23403225700000X
AZMT-22184225700000X
AZMT-22573225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty