Healthcare Provider Details

I. General information

NPI: 1376284117
Provider Name (Legal Business Name): MADELINE MARIE BALS MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

6849 S CAMELOT DR
MENTOR OH
44060-4084
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-1499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.09561
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: