Provider Demographics
NPI:1558773671
Name:PROGRESSIVE BALANCE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PROGRESSIVE BALANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VINCENZO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPH, CHES, GCS
Authorized Official - Phone:479-372-8783
Mailing Address - Street 1:1706 NW MYSTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-8094
Mailing Address - Country:US
Mailing Address - Phone:479-372-8783
Mailing Address - Fax:
Practice Address - Street 1:1706 NW MYSTIC AVE
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-8094
Practice Address - Country:US
Practice Address - Phone:479-372-8783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty