Provider Demographics
NPI:1366940017
Name:BRANDBODYWORKS, INC
Entity type:Organization
Organization Name:BRANDBODYWORKS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS-ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:727-822-2437
Mailing Address - Street 1:5047 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8240
Mailing Address - Country:US
Mailing Address - Phone:727-202-8685
Mailing Address - Fax:727-208-8716
Practice Address - Street 1:5047 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710
Practice Address - Country:US
Practice Address - Phone:727-202-8685
Practice Address - Fax:727-208-8716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM37612225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000873200Medicaid
FL0539414OtherAMERIGROUP