Healthcare Provider Details

I. General information

NPI: 1548615040
Provider Name (Legal Business Name): BALANCE WELL THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26-01 PELLACK DR
FAIR LAWN NJ
07410-3723
US

IV. Provider business mailing address

26-01 PELLACK DR
FAIR LAWN NJ
07410-3723
US

V. Phone/Fax

Practice location:
  • Phone: 201-794-4500
  • Fax: 201-794-4502
Mailing address:
  • Phone: 201-794-4500
  • Fax: 201-794-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA09551100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00608400
License Number StateNJ

VIII. Authorized Official

Name: DR. ROTH LEON RILEY
Title or Position: DIRECTOR
Credential: MD
Phone: 201-794-4500