Healthcare Provider Details

I. General information

NPI: 1568136299
Provider Name (Legal Business Name): BALANCE REGENERATIVE MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 FALLS AVE STE B
TWIN FALLS ID
83301-3370
US

IV. Provider business mailing address

260 FALLS AVE STE B
TWIN FALLS ID
83301-3370
US

V. Phone/Fax

Practice location:
  • Phone: 208-539-3155
  • Fax: 833-505-2716
Mailing address:
  • Phone: 208-539-3155
  • Fax: 833-505-2716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ERICA ANN CAMERON
Title or Position: OWNER
Credential: NP
Phone: 208-539-3155