Healthcare Provider Details

I. General information

NPI: 1477051878
Provider Name (Legal Business Name): BALANCED HEALTH OF PAYSON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 N MAIN ST
PAYSON UT
84651
US

IV. Provider business mailing address

2 N MAIN ST
PAYSON UT
84651-2239
US

V. Phone/Fax

Practice location:
  • Phone: 702-417-8522
  • Fax:
Mailing address:
  • Phone: 702-417-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number8404817-1202
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name: THOR MONGIE
Title or Position: OWNER OF ENTITY
Credential: D.C
Phone: 702-417-8522