=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003761198
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN BAL DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2026
-----------------------------------------------------
Last Update Date | 03/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 E 5TH AVE
-----------------------------------------------------
City | ANTIGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54409-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-623-2331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W5950 SPRINGVIEW DR
-----------------------------------------------------
City | NORWAY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49870-2282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-282-5437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501303858
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 17590-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------