MEDICARE: MOBILE IN-BALANCE DIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory

General Provider Information

NPI Number	:	1134312796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE IN-BALANCE DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	4305 VINELAND RD
Second Line	:	STE G15
City	:	ORLANDO
State	:	FL
Zip	:	32811-7177
Country	:	US
Telephone Number	:	407-451-5897
Fax Number	:	407-386-6267

Provider Business Practice Location Address
First Line	:	4305 VINELAND RD
Second Line	:	STE G15
City	:	ORLANDO
State	:	FL
Zip	:	32811-7177
Country	:	US
Telephone Number	:	407-451-5897
Fax Number	:	407-386-6267

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LEONIDES G FINES
Credential	:
Telephone Number	:	407-451-5897

Provider Enumeration Date	:	08/27/2007
Last Update Date	:	08/27/2007

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