Healthcare Provider Details

I. General information

NPI: 1215365358
Provider Name (Legal Business Name): NATURAL BALANCE PAIN AND WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 ORTIZ DR SE 301-303
ALBUQUERQUE NM
87108-4635
US

IV. Provider business mailing address

6409 SUNNY DAY CT NW
ALBUQUERQUE NM
87120-6144
US

V. Phone/Fax

Practice location:
  • Phone: 815-603-9755
  • Fax:
Mailing address:
  • Phone: 815-603-9755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2007-0654
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number0021
License Number StateNM

VIII. Authorized Official

Name: DR. RANDY LEE JR.
Title or Position: CEO
Credential: DN
Phone: 815-603-9755