=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558635862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDEAL BALANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2012
-----------------------------------------------------
Last Update Date | 08/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6800 HERITAGE PKWY STE 200
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75087-8746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-463-9100
-----------------------------------------------------
Fax | 972-463-9109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6800 HERITAGE PKWY STE 200
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75087-8746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-463-9100
-----------------------------------------------------
Fax | 972-463-9109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PROVIDER
-----------------------------------------------------
Name | DR. JENNA WEBSTER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 972-463-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 11542
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------