Provider Demographics
NPI:1730625609
Name:BODY BALANCE MASSAGE
Entity type:Organization
Organization Name:BODY BALANCE MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BRITTA
Authorized Official - Middle Name:RACHELLE
Authorized Official - Last Name:MAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-414-7382
Mailing Address - Street 1:8450 S 1575 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1376
Mailing Address - Country:US
Mailing Address - Phone:801-414-7382
Mailing Address - Fax:
Practice Address - Street 1:11075 S STATE ST
Practice Address - Street 2:STE 31
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5164
Practice Address - Country:US
Practice Address - Phone:801-414-7382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63903914701302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization