Provider Demographics
NPI:1164095022
Name:BRAIN BODY BALANCE TREATMENT CENTERS
Entity Type:Organization
Organization Name:BRAIN BODY BALANCE TREATMENT CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:JIM
Authorized Official - Last Name:WOLVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-767-8840
Mailing Address - Street 1:640 E 700 S STE 205A
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4023
Mailing Address - Country:US
Mailing Address - Phone:435-767-8840
Mailing Address - Fax:435-359-5120
Practice Address - Street 1:640 E 700 S STE 205A
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4023
Practice Address - Country:US
Practice Address - Phone:435-767-8840
Practice Address - Fax:435-359-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-20
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1730125956Medicaid