Provider Demographics
NPI:1346078755
Name:MODERN BALANCE PROFESSIONAL MASSAGE THERAPY
Entity type:Organization
Organization Name:MODERN BALANCE PROFESSIONAL MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:CUDE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:479-883-9390
Mailing Address - Street 1:PO BOX 783
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-0783
Mailing Address - Country:US
Mailing Address - Phone:479-883-9390
Mailing Address - Fax:
Practice Address - Street 1:101 SW 9TH STREET
Practice Address - Street 2:
Practice Address - City:MULDROW
Practice Address - State:OK
Practice Address - Zip Code:74948
Practice Address - Country:US
Practice Address - Phone:479-883-9390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty