Healthcare Provider Details

I. General information

NPI: 1760097927
Provider Name (Legal Business Name): VITAL BALANCE OSTEOPATHY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BOND STREET STE 1, #290
GREAT NECK NY
11021
US

IV. Provider business mailing address

10 BOND STREET STE 1, #290
GREAT NECK NY
11021
US

V. Phone/Fax

Practice location:
  • Phone: 917-338-1884
  • Fax:
Mailing address:
  • Phone: 917-338-1884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LISA PRESTON
Title or Position: OWNER, PRESIDEN, PHYSICIAN
Credential: DO
Phone: 917-338-1884