Healthcare Provider Details

I. General information

NPI: 1659932655
Provider Name (Legal Business Name): INNER BALANCE FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SE GOLDTREE DRIVE SUITE 207
PORT SAINT LUCIE FL
34952-7583
US

IV. Provider business mailing address

1400 SE GOLDTREE DRIVE SUITE 207
PORT SAINT LUCIE FL
34952-7583
US

V. Phone/Fax

Practice location:
  • Phone: 772-323-0040
  • Fax: 772-237-5849
Mailing address:
  • Phone: 772-323-0040
  • Fax: 772-237-5849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DIONNE LAYNE HINDS
Title or Position: OWNER
Credential: M.D.
Phone: 772-249-0636