Provider Demographics
NPI:1417311184
Name:ADVANCED BALANCE CLINIC LLC
Entity Type:Organization
Organization Name:ADVANCED BALANCE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:DENIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:734-968-6535
Mailing Address - Street 1:1063 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4019
Mailing Address - Country:US
Mailing Address - Phone:734-968-6535
Mailing Address - Fax:
Practice Address - Street 1:1063 WALNUT ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4019
Practice Address - Country:US
Practice Address - Phone:734-968-6535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016376225100000X
MI5201008590225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty