=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972887701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODY BALANCE ACUPUNCTURE & HERB CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2011
-----------------------------------------------------
Last Update Date | 09/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 DTC PKWY STE 400
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-3095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-929-3331
-----------------------------------------------------
Fax | 720-282-0132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 DTC PKWY STE 400
-----------------------------------------------------
City | GREENWOOD VILLAGE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80111-3095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-929-3331
-----------------------------------------------------
Fax | 720-282-0132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SEOUNG R JEE
-----------------------------------------------------
Credential | OMD, LAC
-----------------------------------------------------
Telephone | 303-929-3331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 7086
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 1232
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------