1720671514 NPI number — BALM THERAPEUTIC SERVICES, LLC

Table of content: (NPI 1720671514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720671514 NPI number — BALM THERAPEUTIC SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALM THERAPEUTIC SERVICES, 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:
1720671514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3722 CANDLEWYCK CLUB DR APT D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORISSANT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63034-2585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-616-8919
Provider Business Mailing Address Fax Number:
314-480-7059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 CHURCH ST.
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
FERGUSON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-292-9142
Provider Business Practice Location Address Fax Number:
314-480-7059
Provider Enumeration Date:
02/12/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WARE
Authorized Official First Name:
ERIKA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-292-9142

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 490020305 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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