MEDICARE: BALANCE-VITA PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1235095969
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCE-VITA PLLC

Provider Business Mailing Address
First Line	:	12 W WILLOW GROVE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3952
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 W WILLOW GROVE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3952
Country	:	US
Telephone Number	:	267-270-2446
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MATTHEW WATTO
Credential	:	MD
Telephone Number	:	267-270-2446

Provider Enumeration Date	:	12/26/2025
Last Update Date	:	12/26/2025

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