Provider Demographics
NPI:1881887123
Name:BODY BALANCE ORTHOPEDIC & SPORT PERFORMANCE
Entity type:Organization
Organization Name:BODY BALANCE ORTHOPEDIC & SPORT PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:512-261-8699
Mailing Address - Street 1:311 COPPERLEAF RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4246
Mailing Address - Country:US
Mailing Address - Phone:512-261-8699
Mailing Address - Fax:
Practice Address - Street 1:1 WORLD OF TENNIS SQ
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-1101
Practice Address - Country:US
Practice Address - Phone:512-261-8699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2008-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XH1200X
TX11115242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX611681Medicare PIN