1366795676 NPI number — EASTERN BALANCE ORIENTAL MEDICINE LLC

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 1366795676 NPI number — EASTERN BALANCE ORIENTAL MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN BALANCE ORIENTAL MEDICINE LLC
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:
1366795676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2539 S GESSNER RD
Provider Second Line Business Mailing Address:
SUITE 15
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77063-2034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-922-8179
Provider Business Mailing Address Fax Number:
832-843-0317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2539 S GESSNER RD
Provider Second Line Business Practice Location Address:
SUITE 15
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77063-2034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-922-8179
Provider Business Practice Location Address Fax Number:
832-843-0317
Provider Enumeration Date:
10/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GONG
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
713-922-8179

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC00748 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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