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General NPI Number Information
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NPI Number | 1043596224
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Entity Type | Organization
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Legal Business Name | BALANCED LIFE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 11/01/2011
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Last Update Date | 11/01/2011
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Provider Practice Location Address
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Address Line | 1029 FAIR RD
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City | SIDNEY
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State | OH
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Zip | 45365-8947
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Country | US
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Telephone | 937-492-3800
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Fax | 937-492-3811
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Provider Business Mailing Address
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Address Line | PO BOX 61
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City | MARIA STEIN
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State | OH
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Zip | 45860-0061
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Country | US
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Telephone | 937-492-3800
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Fax | 937-492-3811
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | DR. AMY N HEITKAMP
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Credential | D,C,
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Telephone | 937-492-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | OH-4031
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License Number State | OH
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