1063881795 NPI number — BALANCED LIFE CONCEPTS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063881795 NPI number — BALANCED LIFE CONCEPTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCED LIFE CONCEPTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE FAMILY THAT PLAYS TOGETHER...
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063881795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3102 SE J ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72712-3796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-361-0102
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4306 ATCHISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGDALE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72762-6643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-361-0102
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CARSON
Authorized Official First Name:
TEMPLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
479-361-0102

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  P1207076 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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