Healthcare Provider Details

I. General information

NPI: 1912074568
Provider Name (Legal Business Name): JAMES ALLEN BALMANNO OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 E BRIGGSMORE AVE
MODESTO CA
95355-2707
US

IV. Provider business mailing address

1684 HAVEN ST
OAKDALE CA
95361-8661
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-1211
  • Fax:
Mailing address:
  • Phone: 209-848-3721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: