Provider Demographics
NPI:1124185764
Name:CASADY NICHOLAS BALANCED LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:CASADY NICHOLAS BALANCED LIFE CHIROPRACTIC
Other - Org Name:BALANCED LIFE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:CASADY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-581-3051
Mailing Address - Street 1:7890 HAVEN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-581-3051
Mailing Address - Fax:909-581-3057
Practice Address - Street 1:7890 HAVEN AVE STE 1
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-581-3051
Practice Address - Fax:909-581-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 27728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2341236OtherUNITED HEALTHCARE