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General NPI Number Information
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NPI Number | 1881827947
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Entity Type | Organization
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Legal Business Name | DYNAMIC BALANCE WELLNESS, L.L.C
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Dates
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Enumeration Date | 08/24/2009
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Last Update Date | 08/24/2009
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Provider Practice Location Address
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Address Line | 150 HAZARD AVE STE C7
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City | ENFIELD
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State | CT
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Zip | 06082-4587
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Country | US
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Telephone | 860-749-4148
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Fax | 860-749-4241
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Provider Business Mailing Address
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Address Line | 150 HAZARD AVE STE C7
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City | ENFIELD
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State | CT
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Zip | 06082-4587
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Country | US
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Telephone | 860-749-4148
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Fax | 860-749-4241
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Authorized Official
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Title or Position | OWNER
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Name | CRAIG KELLY
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Credential | LA.C.
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Telephone | 860-749-4148
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 000329
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 01590
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License Number State | CT
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