1073786984 NPI number — BALANCED BODY WELLNESS CENTRE, LLC

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 1073786984 NPI number — BALANCED BODY WELLNESS CENTRE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCED BODY WELLNESS CENTRE, LLC
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:
Provider Other Organization Name Type Code:
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:
1073786984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5150 STILESBORO RD NW
Provider Second Line Business Mailing Address:
SUITE 420
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30152-7744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-425-6068
Provider Business Mailing Address Fax Number:
770-425-6085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5150 STILESBORO RD NW
Provider Second Line Business Practice Location Address:
SUITE 420
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30152-7744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-425-6068
Provider Business Practice Location Address Fax Number:
770-425-6085
Provider Enumeration Date:
04/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FIRNBACH
Authorized Official First Name:
TAMERA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-425-6068

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  CHIR0006878 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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