Provider Demographics
NPI:1679502132
Name:BODMER, DALE MICHAEL (LMT, PT)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:MICHAEL
Last Name:BODMER
Suffix:
Gender:M
Credentials:LMT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3474 CASTLETON ST
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2125
Mailing Address - Country:US
Mailing Address - Phone:614-578-7470
Mailing Address - Fax:855-578-7470
Practice Address - Street 1:4589 KENNY RD STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2778
Practice Address - Country:US
Practice Address - Phone:614-578-7470
Practice Address - Fax:855-578-7470
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.008563225700000X
OH225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist