Provider Demographics
NPI:1255829149
Name:BALANCE FAMILY PRACTICE & MEDICAL SPA LLC
Entity Type:Organization
Organization Name:BALANCE FAMILY PRACTICE & MEDICAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:SCARLETT
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:VIRDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP APRN FNP-C
Authorized Official - Phone:918-397-5437
Mailing Address - Street 1:10330 STATE HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74056
Mailing Address - Country:US
Mailing Address - Phone:918-397-5437
Mailing Address - Fax:918-398-9316
Practice Address - Street 1:10330 STATE HWY 10
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056
Practice Address - Country:US
Practice Address - Phone:918-397-5437
Practice Address - Fax:918-398-9316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK93576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200789230AMedicaid