Basic Information
| Provider Information | |||||||||
| NPI: | 1891160552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLEYVILLE BODY FOCUS WELLNESS CLINIC, LLC | ||||||||
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| OtherOrganizationName: | JUVIA MED SPA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9101 LBJ FWY | ||||||||
| Address2: | STE 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752432057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727925700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4620 COLLEYVILLE BLVD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760343971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174273700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2015 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAVUS | ||||||||
| AuthorizedOfficialFirstName: | CHERI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9727925700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N5550 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207L00000X | N5550 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | N5550 | 01 | TX | TMB | OTHER |