Provider Demographics
NPI:1780057968
Name:ACTIVE BALANCE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:ACTIVE BALANCE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STUTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:307-655-2509
Mailing Address - Street 1:PO BOX 1064
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WY
Mailing Address - Zip Code:82836-1064
Mailing Address - Country:US
Mailing Address - Phone:307-655-2509
Mailing Address - Fax:307-655-2275
Practice Address - Street 1:512 MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WY
Practice Address - Zip Code:82836-5056
Practice Address - Country:US
Practice Address - Phone:307-655-2509
Practice Address - Fax:370-655-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-0964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty