Healthcare Provider Details

I. General information

NPI: 1780531723
Provider Name (Legal Business Name): A BALANCED LIFE ANTI-AGING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E COURTLAND ST
MORTON IL
61550-9054
US

IV. Provider business mailing address

370 E COURTLAND ST
MORTON IL
61550-9054
US

V. Phone/Fax

Practice location:
  • Phone: 309-291-0899
  • Fax:
Mailing address:
  • Phone: 309-291-0899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: YESENIA SERVIN
Title or Position: DIRECTOR
Credential: CPMSM
Phone: 708-979-9082