Healthcare Provider Details

I. General information

NPI: 1811390297
Provider Name (Legal Business Name): BALANCED LIVING INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136-81 71ST ROAD
FLUSHING NY
11367-1942
US

IV. Provider business mailing address

136-81 71ST ROAD
FLUSHING NY
11367-1942
US

V. Phone/Fax

Practice location:
  • Phone: 718-544-4036
  • Fax: 718-544-4036
Mailing address:
  • Phone: 718-544-4036
  • Fax: 718-544-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: DR. RICK SHIELDS
Title or Position: PRESIDENT
Credential: CDN
Phone: 718-544-4036