Healthcare Provider Details

I. General information

NPI: 1417311184
Provider Name (Legal Business Name): ADVANCED BALANCE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 05/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1063 WALNUT ST
DEARBORN MI
48124-4019
US

IV. Provider business mailing address

1063 WALNUT ST
DEARBORN MI
48124-4019
US

V. Phone/Fax

Practice location:
  • Phone: 734-968-6535
  • Fax:
Mailing address:
  • Phone: 734-968-6535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016376
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201008590
License Number StateMI

VIII. Authorized Official

Name: BRITTANY DENIS
Title or Position: CO-OWNER
Credential: PT, DPT
Phone: 734-968-6535