=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780710194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI CITY BALANCE CENTER S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 RANDALL RD # 104-A
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60134-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-377-4020
-----------------------------------------------------
Fax | 630-377-4023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 RANDALL RD # 104-A
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60134-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-377-4020
-----------------------------------------------------
Fax | 630-377-4023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL MANAGER
-----------------------------------------------------
Name | DR. RONALD B BUKOWY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-377-4020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 36052366
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------