Provider Demographics
NPI:1700082484
Name:BODIES IN BALANCE OF TWO HARBORS, INC.
Entity Type:Organization
Organization Name:BODIES IN BALANCE OF TWO HARBORS, INC.
Other - Org Name:BODIES IN BALANCE INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PHIPPS-POE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:218-834-2586
Mailing Address - Street 1:1313 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-4600
Mailing Address - Country:US
Mailing Address - Phone:218-834-2586
Mailing Address - Fax:
Practice Address - Street 1:1313 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-4600
Practice Address - Country:US
Practice Address - Phone:218-834-2586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1700922960Medicare PIN