Basic Information
| Provider Information | |||||||||
| NPI: | 1336656701 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALANCED FLOW MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 W ONTARIO ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606543621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128809697 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 W ONTARIO ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606543621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128809697 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2018 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | MALINOWSKA HERTSBERG | ||||||||
| AuthorizedOfficialFirstName: | DOMINIKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3128809697 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 208D00000X | 038012628 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1225442502 | 05 | IL | MEDICAID |