Healthcare Provider Details

I. General information

NPI: 1174170161
Provider Name (Legal Business Name): BALANCED OUTPATIENT THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 JENSEN DR # 101
VIRGINIA BEACH VA
23451-5872
US

IV. Provider business mailing address

1142 JENSEN DR # 101
VIRGINIA BEACH VA
23451-5872
US

V. Phone/Fax

Practice location:
  • Phone: 757-965-9942
  • Fax: 757-222-1103
Mailing address:
  • Phone: 757-965-9942
  • Fax: 757-222-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW SILVER
Title or Position: PRESIDENT
Credential: PT
Phone: 609-306-9750