1255907556 NPI number — KEEP ME BALANCED HEALTH CLINIC, PLLC

Table of content: (NPI 1255907556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255907556 NPI number — KEEP ME BALANCED HEALTH CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEEP ME BALANCED HEALTH CLINIC, PLLC
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:
1255907556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9718 PEACH TREE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROWLETT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75089-8436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-234-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 E BELT LINE RD # 1015
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHARDSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75081-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-234-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
KENDRA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
504-234-7000

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AP139703 . This is a "TX BON" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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