MEDICARE: BALANCED WELLNESS 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1295128908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCED WELLNESS LLC

Provider Business Mailing Address
First Line	:	1966 NE 123RD ST
Second Line	:	SUITE #223
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2868
Country	:	US
Telephone Number	:	786-709-7912
Fax Number	:

Provider Business Practice Location Address
First Line	:	1966 NE 123RD ST
Second Line	:	SUITE #223
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2868
Country	:	US
Telephone Number	:	786-709-7912
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT NIZNIK
Credential	:
Telephone Number	:	786-709-7912

Provider Enumeration Date	:	03/05/2015
Last Update Date	:	03/05/2015

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