1154692747 NPI number — BALANCE AND FALL PREVENTION CLINIC, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154692747 NPI number — BALANCE AND FALL PREVENTION CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCE AND FALL PREVENTION CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154692747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
173 S MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELYSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17824-9757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-672-2277
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
173 S MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELYSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17824-9757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-672-2277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STOUT
Authorized Official First Name:
MARY
Authorized Official Middle Name:
THERESA
Authorized Official Title or Position:
CEO/THERAPIST
Authorized Official Telephone Number:
570-672-2277

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  PT001749E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 412246 . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".