Healthcare Provider Details

I. General information

NPI: 1801322375
Provider Name (Legal Business Name): NIKOLAS RYAN BALAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 ROUTE 112
CORAM NY
11727-4116
US

IV. Provider business mailing address

3600 ROUTE 112
CORAM NY
11727-4116
US

V. Phone/Fax

Practice location:
  • Phone: 631-920-8500
  • Fax: 631-920-8501
Mailing address:
  • Phone: 631-920-8500
  • Fax: 631-920-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number32468
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: