Healthcare Provider Details

I. General information

NPI: 1720354046
Provider Name (Legal Business Name): BODY BALANCE MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 SOUTHPOINT PKWY SUITE 801
JACKSONVILLE FL
32216
US

IV. Provider business mailing address

6817 SOUTHPOINT PKWY SUITE 801
JACKSONVILLE FL
32216
US

V. Phone/Fax

Practice location:
  • Phone: 904-647-6485
  • Fax:
Mailing address:
  • Phone: 904-647-6485
  • Fax: 904-647-6136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME20849
License Number StateFL

VIII. Authorized Official

Name: DAVID W MOBLEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 904-647-6485