Provider Demographics
NPI:1497210850
Name:FUNCTIONALLY BALANCED BODYWORK CLINICS, LLC
Entity Type:Organization
Organization Name:FUNCTIONALLY BALANCED BODYWORK CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, BCTMB
Authorized Official - Phone:773-556-5333
Mailing Address - Street 1:3850 W 95TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2006
Mailing Address - Country:US
Mailing Address - Phone:708-529-7111
Mailing Address - Fax:708-843-5811
Practice Address - Street 1:3850 W 95TH ST FL 1
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2006
Practice Address - Country:US
Practice Address - Phone:708-529-7111
Practice Address - Fax:708-843-5811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty