=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588910525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALAREZO FAMILY CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2012
-----------------------------------------------------
Last Update Date | 04/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 NE 164TH ST
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33162-4109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-454-9610
-----------------------------------------------------
Fax | 305-705-3524
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 NE 164TH ST
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33162-4109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-454-9610
-----------------------------------------------------
Fax | 305-705-3524
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. BENJAMIN C BALAREZO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 305-951-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | CH9439
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------