Basic Information
| Provider Information | |||||||||
| NPI: | 1922254903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BALANCED BODY PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 307 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012946907 | ||||||||
| FaxNumber: | 8012946917 | ||||||||
| Practice Location | |||||||||
| Address1: | 4465 S 900 E | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841242456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012938888 | ||||||||
| FaxNumber: | 8012938890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2008 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | LOVELL | ||||||||
| AuthorizedOfficialFirstName: | DALLEN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8012938888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1187252401 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.