Provider Demographics
NPI:1255812715
Name:PHYSIO BALANCE AND SPORTS PERFORMANCE, LLC
Entity type:Organization
Organization Name:PHYSIO BALANCE AND SPORTS PERFORMANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VERRELLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:330-942-3316
Mailing Address - Street 1:1587 BOETTLER RD STE 140
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-7823
Mailing Address - Country:US
Mailing Address - Phone:330-687-6891
Mailing Address - Fax:330-362-2623
Practice Address - Street 1:1587 BOETTLER RD STE 140
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685
Practice Address - Country:US
Practice Address - Phone:330-687-6891
Practice Address - Fax:330-362-2623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty