1124404272 NPI number — BALANCE INTEGRATIVE HEALTH & WELLNESS

Table of content: (NPI 1124404272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124404272 NPI number — BALANCE INTEGRATIVE HEALTH & WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCE INTEGRATIVE HEALTH & WELLNESS
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:
1124404272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4855 ASBURY RD STE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBUQUE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52002-0483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-284-2422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4855 ASBURY RD
Provider Second Line Business Practice Location Address:
STE #7
Provider Business Practice Location Address City Name:
DUBUQUE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52002-0483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-284-2422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GRUTZ
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
563-663-1248

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  A122623 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com