Provider Demographics
NPI:1164696845
Name:BALLISTREA, STEPHEN ANTHONY (DC, BS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANTHONY
Last Name:BALLISTREA
Suffix:
Gender:M
Credentials:DC, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7236 STATE ROAD 52 STE 3
Mailing Address - Street 2:
Mailing Address - City:BAYONET POINT
Mailing Address - State:FL
Mailing Address - Zip Code:34667-6749
Mailing Address - Country:US
Mailing Address - Phone:727-868-4444
Mailing Address - Fax:727-868-2892
Practice Address - Street 1:7236 STATE ROAD 52
Practice Address - Street 2:SUITE 3
Practice Address - City:BAYONET POINT
Practice Address - State:FL
Practice Address - Zip Code:34667-6789
Practice Address - Country:US
Practice Address - Phone:727-868-4444
Practice Address - Fax:727-868-2892
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8075111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU86609 0001Medicare UPIN