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General NPI Number Information
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NPI Number | 1700132743
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Entity Type | Organization
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Legal Business Name | BODY BALANCE SPA, LLC
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Dates
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Enumeration Date | 07/27/2012
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Last Update Date | 07/27/2012
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Provider Practice Location Address
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Address Line | 1997 S MAIN ST STE 604E
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City | BLACKSBURG
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State | VA
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Zip | 24060-6606
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Country | US
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Telephone | 540-449-3035
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11222
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City | BLACKSBURG
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State | VA
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Zip | 24062-1222
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Country | US
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Telephone | 540-449-3035
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | MRS. CARRIE E BOUCHER
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Credential | LMT
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Telephone | 540-449-3035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | S376257-4
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License Number State | VA
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