=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619231255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED BODYWORK CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2012
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 E ROYALTON RD #7
-----------------------------------------------------
City | BROADVIEW HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44147-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-539-2014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 VINEYARD DR 402
-----------------------------------------------------
City | BROADVIEW HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44147-3390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-539-2014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANTHONY JOSEPH BIONDILLO III
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 440-539-2014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4288
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------