Healthcare Provider Details

I. General information

NPI: 1245496603
Provider Name (Legal Business Name): AMBER LEIGH BALBACH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E MAIN ST STE E
CARMEL IN
46032-1782
US

IV. Provider business mailing address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

V. Phone/Fax

Practice location:
  • Phone: 317-561-0183
  • Fax:
Mailing address:
  • Phone: 317-988-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number964795
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: