Provider Demographics
NPI:1205375433
Name:EQUILIBRIUM LLC
Entity Type:Organization
Organization Name:EQUILIBRIUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MELCHIOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-870-5380
Mailing Address - Street 1:4624 XERXES AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4570 W 77TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5008
Practice Address - Country:US
Practice Address - Phone:952-500-8733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 83440225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty