MEDICARE: BALANCED MEDICINE 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	261QP2300X	Primary Care Clinic/Center	34007781S	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891853271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCED MEDICINE LLC

Provider Business Mailing Address
First Line	:	29002 ROCKSTULL RD
Second Line	:
City	:	SUGAR GROVE
State	:	OH
Zip	:	43155-9644
Country	:	US
Telephone Number	:	740-746-0453
Fax Number	:	740-743-0453

Provider Business Practice Location Address
First Line	:	29002 ROCKSTULL RD
Second Line	:
City	:	SUGAR GROVE
State	:	OH
Zip	:	43155-9644
Country	:	US
Telephone Number	:	740-746-0453
Fax Number	:	740-743-0453

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	MRS. GABRIELA B GOSS
Credential	:	DO
Telephone Number	:	740-746-0453

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	03/12/2008

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