1588667745 NPI number — BALANCED LIVING CHIROPRACTIC CLINIC, INC

Table of content: MS. TRISHA SEWPAUL LCSW-C (NPI 1184930695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588667745 NPI number — BALANCED LIVING CHIROPRACTIC CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCED LIVING CHIROPRACTIC 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:
1588667745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
708 E SMITH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDINA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44256-2662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-725-5277
Provider Business Mailing Address Fax Number:
330-725-4241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 E SMITH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDINA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44256-2662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-725-5277
Provider Business Practice Location Address Fax Number:
330-725-4241
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BITSKAY
Authorized Official First Name:
JEANINE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-725-5277

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1685 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 1734 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0221638 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34178207500 . This is a "BWC- DR. MARK" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 131566870-005 . This is a "MEDICAL MUTUAL-DR. MARK" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34177451400 . This is a "BWC-DR. JEANINE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000139760 . This is a "ANTHEM-DR.MARK" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000139761 . This is a "ANTHEM-DR.JEANINE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0826020 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0857210 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200505615-006 . This is a "MEDICAL MUTUAL-DR.JEANINE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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