Provider Demographics
NPI:1124431564
Name:BACK TO BALANCE LLC
Entity type:Organization
Organization Name:BACK TO BALANCE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARREL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-998-9151
Mailing Address - Street 1:451 S 1ST AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-3972
Mailing Address - Country:US
Mailing Address - Phone:503-998-9151
Mailing Address - Fax:503-305-3916
Practice Address - Street 1:451 S 1ST AVE STE 300
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-3972
Practice Address - Country:US
Practice Address - Phone:503-998-9151
Practice Address - Fax:503-305-3916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20197225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20197OtherMASSAGE LICENSE
OR1124431564Medicaid