Provider Demographics
NPI:1548416829
Name:WELL BALANCED BODY INC
Entity type:Organization
Organization Name:WELL BALANCED BODY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHEENA
Authorized Official - Middle Name:NIETO
Authorized Official - Last Name:BURKHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS
Authorized Official - Phone:949-553-8853
Mailing Address - Street 1:PO BOX 6356
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92616-6356
Mailing Address - Country:US
Mailing Address - Phone:949-553-8853
Mailing Address - Fax:949-553-8883
Practice Address - Street 1:1124 MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6760
Practice Address - Country:US
Practice Address - Phone:949-553-8853
Practice Address - Fax:949-553-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24551261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 24551Medicare PIN