Provider Demographics
NPI:1023014859
Name:BODY BALANCE GOLF & PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:BODY BALANCE GOLF & PHYSICAL THERAPY, LLC
Other - Org Name:BODY BALANCE FOR PERFORMANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WIEBER
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:952-888-9549
Mailing Address - Street 1:2070 W 96TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2517
Mailing Address - Country:US
Mailing Address - Phone:952-888-9549
Mailing Address - Fax:952-703-3481
Practice Address - Street 1:2070 W 96TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-2517
Practice Address - Country:US
Practice Address - Phone:952-888-9549
Practice Address - Fax:952-703-3481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
394M1BOOtherBLUE CROSS & BLUE SHIELD
C04225Medicare PIN