Provider Demographics
NPI:1891421467
Name:BRAIN BALANCE LIFE BALANCE INC
Entity Type:Organization
Organization Name:BRAIN BALANCE LIFE BALANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:505-436-2347
Mailing Address - Street 1:719 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5512
Mailing Address - Country:US
Mailing Address - Phone:505-436-2347
Mailing Address - Fax:505-278-8939
Practice Address - Street 1:719 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5512
Practice Address - Country:US
Practice Address - Phone:505-436-2347
Practice Address - Fax:505-278-8939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty