Provider Demographics
NPI:1164611141
Name:BALLARD ENTERPRISE, L.L.C
Entity Type:Organization
Organization Name:BALLARD ENTERPRISE, L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:KERRY
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-536-3550
Mailing Address - Street 1:1083 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5582
Mailing Address - Country:US
Mailing Address - Phone:928-536-3550
Mailing Address - Fax:928-536-3550
Practice Address - Street 1:1083 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5582
Practice Address - Country:US
Practice Address - Phone:928-536-3550
Practice Address - Fax:928-536-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6020111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z77372Medicare PIN