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General NPI Number Information
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NPI Number | 1578585576
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Entity Type | Organization
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Legal Business Name | ENRICO BALCOS MEDICAL INC
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 09/09/2011
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Provider Practice Location Address
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Address Line | 4619 ROSEMEAD BLVD
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City | ROSEMEAD
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State | CA
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Zip | 91770-1478
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Country | US
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Telephone | 626-286-1191
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Fax | 949-258-5551
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Provider Business Mailing Address
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Address Line | PO BOX 1526
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City | SOUTH PASADENA
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State | CA
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Zip | 91031-1526
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Country | US
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Telephone | 888-518-5445
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Fax | 949-258-5551
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Authorized Official
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Title or Position | CORP PRESIDENT
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Name | ENRICO U BALCOS
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Credential | MD
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Telephone | 888-518-5445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | A63363
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License Number State | CA
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