Provider Demographics
NPI:1679869408
Name:BODY FOR LIFE LLC
Entity type:Organization
Organization Name:BODY FOR LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-373-3300
Mailing Address - Street 1:8099 STAGE HILLS BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4064
Mailing Address - Country:US
Mailing Address - Phone:901-373-3300
Mailing Address - Fax:901-373-3303
Practice Address - Street 1:8099 STAGE HILLS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4064
Practice Address - Country:US
Practice Address - Phone:901-373-3300
Practice Address - Fax:901-373-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN12232363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty