Basic Information
Provider Information | |||||||||
NPI: | 1437536208 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BALANCED FLOW WELLNESS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BALANCED FLOW WELLNESS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 747 N. LASALLE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3128809697 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 747 N LASALLE | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606545089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3128809697 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/30/2015 | ||||||||
LastUpdateDate: | 04/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEE | ||||||||
AuthorizedOfficialFirstName: | NOLAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
AuthorizedOfficialTelephone: | 3122963569 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.C. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038012628 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   | 111N00000X | 038012631 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   |
No ID Information.