Provider Demographics
NPI:1255979035
Name:BALANCED PHYSICAL THERAPY & SPORTS PERFORMANCE
Entity type:Organization
Organization Name:BALANCED PHYSICAL THERAPY & SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULTINEER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:919-803-1037
Mailing Address - Street 1:2620 KINLAWTON PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-9867
Mailing Address - Country:US
Mailing Address - Phone:717-615-2704
Mailing Address - Fax:
Practice Address - Street 1:6520 FALLS OF NEUSE RD STE 110
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6849
Practice Address - Country:US
Practice Address - Phone:919-803-1037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy