=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891421467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAIN BALANCE LIFE BALANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2022
-----------------------------------------------------
Last Update Date | 07/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 W APACHE ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-5512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-436-2347
-----------------------------------------------------
Fax | 505-278-8939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 719 W APACHE ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-5512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-436-2347
-----------------------------------------------------
Fax | 505-278-8939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE CASE MANAGER
-----------------------------------------------------
Name | VIDA M GUFFEY
-----------------------------------------------------
Credential | REGISTERED NURSE
-----------------------------------------------------
Telephone | 505-436-2347
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------