Provider Demographics
NPI:1700132743
Name:BODY BALANCE SPA, LLC
Entity type:Organization
Organization Name:BODY BALANCE SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:540-449-3035
Mailing Address - Street 1:PO BOX 11222
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24062-1222
Mailing Address - Country:US
Mailing Address - Phone:540-449-3035
Mailing Address - Fax:
Practice Address - Street 1:1997 S MAIN ST STE 604E
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6606
Practice Address - Country:US
Practice Address - Phone:540-449-3035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS376257-4261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation