Healthcare Provider Details

I. General information

NPI: 1033035878
Provider Name (Legal Business Name): LILY BALANOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E 43RD ST STE 1223
GARDEN CITY ID
83714-4925
US

IV. Provider business mailing address

521 E 41ST ST APT 302
GARDEN CITY ID
83714-6625
US

V. Phone/Fax

Practice location:
  • Phone: 208-562-7325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2671941
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: