MEDICARE: HEALTH BALANCE INTERNATIONAL

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1467601674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTH BALANCE INTERNATIONAL

Provider Business Mailing Address
First Line	:	1627 FOOTHILL DR
Second Line	:	SUITE 10
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2739
Country	:	US
Telephone Number	:	801-688-2628
Fax Number	:	801-906-0735

Provider Business Practice Location Address
First Line	:	1627 FOOTHILL DR
Second Line	:	SUITE 10
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2739
Country	:	US
Telephone Number	:	801-688-2628
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. CHARLES MCCUSKER
Credential	:
Telephone Number	:	801-688-2628

Provider Enumeration Date	:	09/11/2008
Last Update Date	:	09/11/2008

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