Healthcare Provider Details

I. General information

NPI: 1790654945
Provider Name (Legal Business Name): BLALANCE4LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7951 ETIWANDA AVE APT 2104 2104
RANCHO CUCAMONGA CA
91739-6701
US

IV. Provider business mailing address

7951 ETIWANDA AVE APT 2104
RANCHO CUCAMONGA CA
91739-6701
US

V. Phone/Fax

Practice location:
  • Phone: 909-276-4393
  • Fax:
Mailing address:
  • Phone: 909-276-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY ALLEN
Title or Position: MEMBER
Credential:
Phone: 909-276-4393