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General NPI Number Information
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NPI Number | 1780926774
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Entity Type | Organization
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Legal Business Name | BALANCED WELLNESS PRIMARY CARE, LLC
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Dates
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Enumeration Date | 03/18/2013
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Last Update Date | 06/17/2022
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Provider Practice Location Address
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Address Line | 620 NORWICH NEW LONDON TPKE
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City | UNCASVILLE
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State | CT
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Zip | 06382
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Country | US
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Telephone | 860-892-8012
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Fax | 860-892-8027
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Provider Business Mailing Address
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Address Line | 620 NORWICH NEW LONDON TPKE
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City | UNCASVILLE
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State | CT
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Zip | 06382
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Country | US
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Telephone | 860-892-8012
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Fax | 860-892-8027
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Authorized Official
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Title or Position | OWNER
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Name | KRISTIN MARIE MAHAN
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Credential |
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Telephone | 860-892-8012
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 004797
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License Number State | CT
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