Provider Demographics
NPI:1104012319
Name:PRO BALANCE LLC
Entity Type:Organization
Organization Name:PRO BALANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GILGIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUMBS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:423-246-7272
Mailing Address - Street 1:2408 FORT HENRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664
Mailing Address - Country:US
Mailing Address - Phone:423-246-7272
Mailing Address - Fax:423-246-2803
Practice Address - Street 1:2408 FORT HENRY DRIVE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664
Practice Address - Country:US
Practice Address - Phone:423-246-7272
Practice Address - Fax:423-246-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO16335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454327Medicaid
TN4522550001Medicare NSC