Healthcare Provider Details

I. General information

NPI: 1184337933
Provider Name (Legal Business Name): BALANCED LIFE OSTEOPATHY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2022
Last Update Date: 12/26/2022
Certification Date: 12/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1559 SUMMIT AVE
SAINT PAUL MN
55105-2244
US

IV. Provider business mailing address

1559 SUMMIT AVE
SAINT PAUL MN
55105-2244
US

V. Phone/Fax

Practice location:
  • Phone: 612-367-6445
  • Fax:
Mailing address:
  • Phone: 612-367-6445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSANNE MURPHY
Title or Position: OWNER
Credential: DO
Phone: 612-367-6445