Healthcare Provider Details

I. General information

NPI: 1023014859
Provider Name (Legal Business Name): BODY BALANCE GOLF & PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2070 W 96TH ST
BLOOMINGTON MN
55431-2517
US

IV. Provider business mailing address

2070 W 96TH ST
BLOOMINGTON MN
55431-2517
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-9549
  • Fax: 952-703-3481
Mailing address:
  • Phone: 952-888-9549
  • Fax: 952-703-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID JOHN WIEBER
Title or Position: OWNER
Credential: LPT
Phone: 952-888-9549