MEDICARE: LIFE BALANCE MEDICAL GROUP 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1336775733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE BALANCE MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	PO BOX 151686
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33684-1686
Country	:	US
Telephone Number	:	813-443-8221
Fax Number	:	813-443-1869

Provider Business Practice Location Address
First Line	:	2916 W WATERS AVE STE A1
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1869
Country	:	US
Telephone Number	:	813-443-8221
Fax Number	:	813-443-1869

Authorized Official
Title or Position	:	OWNER
Name	:	PEDRO M HERNANDEZ
Credential	:
Telephone Number	:	813-443-8221

Provider Enumeration Date	:	03/17/2020
Last Update Date	:	09/21/2021

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Directions to “LIFE BALANCE MEDICAL GROUP LLC ” Practice Location

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