Provider Demographics
NPI:1174770010
Name:GRAVITY BODY FITNESS & STRUCTURAL ACADEMY
Entity type:Organization
Organization Name:GRAVITY BODY FITNESS & STRUCTURAL ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:858-232-3708
Mailing Address - Street 1:1050 E. RIVER ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718
Mailing Address - Country:US
Mailing Address - Phone:520-495-0438
Mailing Address - Fax:
Practice Address - Street 1:1050 E. RIVER ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718
Practice Address - Country:US
Practice Address - Phone:520-495-0438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225500000X
CA447028-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty