Provider Demographics
NPI:1174576177
Name:BODY STRUCTURE CLINIC INC.
Entity type:Organization
Organization Name:BODY STRUCTURE CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BALCIRAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-268-8190
Mailing Address - Street 1:2600 GRIBBIN DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4498
Mailing Address - Country:US
Mailing Address - Phone:859-268-8190
Mailing Address - Fax:859-268-8923
Practice Address - Street 1:2600 GRIBBIN DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4498
Practice Address - Country:US
Practice Address - Phone:859-268-8190
Practice Address - Fax:859-268-8923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000061166OtherANTHEM BCBS
KY000000061166OtherANTHEM BCBS