Healthcare Provider Details

I. General information

NPI: 1114605227
Provider Name (Legal Business Name): LOVING LIFE WITH BALANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10077 WOODLEE CV
CORDOVA TN
38016-0367
US

IV. Provider business mailing address

10077 WOODLEE CV
CORDOVA TN
38016-0367
US

V. Phone/Fax

Practice location:
  • Phone: 520-542-2035
  • Fax: 877-540-0067
Mailing address:
  • Phone: 520-542-2035
  • Fax: 877-540-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ROSALINDA LOGAN-PETERS
Title or Position: REVENUE CYCLE MANAGER
Credential: CPC, CPPM,COBGC,BSN
Phone: 520-416-6639