Provider Demographics
NPI:1487845400
Name:EQUILIBRIUM BALANCE PERFORMANCE CENTER PHYSICAL THERAPY A PROF. CORP.
Entity Type:Organization
Organization Name:EQUILIBRIUM BALANCE PERFORMANCE CENTER PHYSICAL THERAPY A PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT
Authorized Official - Phone:805-339-9718
Mailing Address - Street 1:1673 DONLON ST STE 201
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5668
Mailing Address - Country:US
Mailing Address - Phone:805-339-9718
Mailing Address - Fax:805-339-9728
Practice Address - Street 1:1673 DONLON ST STE 201
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5668
Practice Address - Country:US
Practice Address - Phone:805-339-9718
Practice Address - Fax:805-339-9728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 27784261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ62926ZOtherBLUE SHIELD OF CALIFORNIA
CAZZZ62926ZOtherBLUE SHIELD OF CALIFORNIA