Provider Demographics
NPI:1295181584
Name:BALANCED WELL MEDICAL NETWORK
Entity Type:Organization
Organization Name:BALANCED WELL MEDICAL NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROTH
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-794-4500
Mailing Address - Street 1:23-08 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1583
Mailing Address - Country:US
Mailing Address - Phone:201-794-4500
Mailing Address - Fax:201-794-4502
Practice Address - Street 1:23-08 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1583
Practice Address - Country:US
Practice Address - Phone:201-794-4500
Practice Address - Fax:201-794-4502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BALANCED WELL MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09551100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty