Healthcare Provider Details

I. General information

NPI: 1063074565
Provider Name (Legal Business Name): BALANCE FOOT AND ANKLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 GREAT EAST NECK RD
WEST BABYLON NY
11704-7801
US

IV. Provider business mailing address

5 MARLBOROUGH CT
ROCKVILLE CENTRE NY
11570-1822
US

V. Phone/Fax

Practice location:
  • Phone: 516-344-5553
  • Fax:
Mailing address:
  • Phone: 845-596-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: TYLER MIRANDA
Title or Position: OWNER
Credential: DPM
Phone: 845-596-4745