Provider Demographics
NPI:1114405412
Name:PERFECT BALANCE BOUTIQUE
Entity Type:Organization
Organization Name:PERFECT BALANCE BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:GERHARD
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:484-464-3295
Mailing Address - Street 1:813 FREDERICKS GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-9661
Mailing Address - Country:US
Mailing Address - Phone:484-464-3295
Mailing Address - Fax:
Practice Address - Street 1:813 FREDERICKS GROVE RD
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-9661
Practice Address - Country:US
Practice Address - Phone:484-464-3295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Single Specialty