Healthcare Provider Details

I. General information

NPI: 1679942783
Provider Name (Legal Business Name): LIFE BALANCE PHYSICAL THERAPY AND WELLNESS SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 W MAPLE ST
SEQUIM WA
98382-3773
US

IV. Provider business mailing address

136 W MAPLE ST
SEQUIM WA
98382-3773
US

V. Phone/Fax

Practice location:
  • Phone: 586-764-0430
  • Fax:
Mailing address:
  • Phone: 586-764-0430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number60076825
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. KELLY RUTT
Title or Position: OWNER, PHYSICAL THERAPIST
Credential: MPT
Phone: 586-764-0430