Healthcare Provider Details

I. General information

NPI: 1578446183
Provider Name (Legal Business Name): MARC KIRIT BALATERO MSN, RN, CNL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST STE 1080
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

11224 BRADDOCK DR
CULVER CITY CA
90230-4807
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7117
  • Fax:
Mailing address:
  • Phone: 310-993-8618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number95112768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: