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General NPI Number Information
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NPI Number | 1780531723
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Entity Type | Organization
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Legal Business Name | A BALANCED LIFE ANTI-AGING CLINIC
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Dates
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Enumeration Date | 03/10/2026
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Last Update Date | 03/10/2026
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Provider Practice Location Address
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Address Line | 370 E COURTLAND ST
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City | MORTON
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State | IL
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Zip | 61550-9054
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Country | US
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Telephone | 309-291-0899
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Fax |
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Provider Business Mailing Address
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Address Line | 370 E COURTLAND ST
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City | MORTON
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State | IL
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Zip | 61550-9054
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Country | US
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Telephone | 309-291-0899
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | YESENIA SERVIN
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Credential | CPMSM
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Telephone | 708-979-9082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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