Healthcare Provider Details

I. General information

NPI: 1881827947
Provider Name (Legal Business Name): DYNAMIC BALANCE WELLNESS, L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 HAZARD AVE STE C7
ENFIELD CT
06082-4587
US

IV. Provider business mailing address

150 HAZARD AVE STE C7
ENFIELD CT
06082-4587
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-4148
  • Fax: 860-749-4241
Mailing address:
  • Phone: 860-749-4148
  • Fax: 860-749-4241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number01590
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000329
License Number StateCT

VIII. Authorized Official

Name: CRAIG KELLY
Title or Position: OWNER
Credential: LA.C.
Phone: 860-749-4148