Healthcare Provider Details

I. General information

NPI: 1700114147
Provider Name (Legal Business Name): KINETIC BALANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39149 FRY FARM RD
LOVETTSVILLE VA
20180
US

IV. Provider business mailing address

39149 FRY FARM RD
LOVETTSVILLE VA
20180-2749
US

V. Phone/Fax

Practice location:
  • Phone: 703-994-4834
  • Fax: 703-649-6049
Mailing address:
  • Phone: 703-994-4834
  • Fax: 703-649-6049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2305204182
License Number StateVA

VIII. Authorized Official

Name: MRS. CATHERINE WYCOFF
Title or Position: OWNER
Credential: PT
Phone: 703-994-4834