Provider Demographics
NPI:1033778451
Name:BALANCED SPINE & WELLNESS, LLC
Entity Type:Organization
Organization Name:BALANCED SPINE & WELLNESS, LLC
Other - Org Name:BALANCED SPINE & WELLNESS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TELISHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVERICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-681-4173
Mailing Address - Street 1:6200 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-0506
Mailing Address - Country:US
Mailing Address - Phone:605-681-4173
Mailing Address - Fax:
Practice Address - Street 1:6705 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-1290
Practice Address - Country:US
Practice Address - Phone:605-636-5013
Practice Address - Fax:202-967-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1528419462OtherNPI