=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164027363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCE MASSAGE AND YOGA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2020
-----------------------------------------------------
Last Update Date | 12/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 356 S MCCULLOCH BLVD STE 102
-----------------------------------------------------
City | PUEBLO WEST
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-2848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-251-7989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6977
-----------------------------------------------------
City | PUEBLO WEST
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-6977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-369-7968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER NOEL KLIPFEL
-----------------------------------------------------
Credential | CMT, CMLDT
-----------------------------------------------------
Telephone | 719-369-7368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------