Healthcare Provider Details

I. General information

NPI: 1043678931
Provider Name (Legal Business Name): NATURAL BALANCE ORTHOTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 JOHNS DR
GLENVIEW IL
60025-1657
US

IV. Provider business mailing address

1864 JOHNS DR
GLENVIEW IL
60025-1657
US

V. Phone/Fax

Practice location:
  • Phone: 847-729-7923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016.002683
License Number StateIL

VIII. Authorized Official

Name: JASON BERGMANN
Title or Position: PRESIDENT
Credential: CPED
Phone: 847-729-7923