Healthcare Provider Details

I. General information

NPI: 1659998326
Provider Name (Legal Business Name): BALANCED HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 MAIN ST APT D
EVANSTON IL
60202-1688
US

IV. Provider business mailing address

1614 MAIN ST
EVANSTON IL
60202-1688
US

V. Phone/Fax

Practice location:
  • Phone: 515-718-5468
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMAAL APPLEWHITE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 515-718-5468