Provider Demographics
NPI:1467908145
Name:BALCA, JACOB DAVID (ATS STUDENT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DAVID
Last Name:BALCA
Suffix:
Gender:M
Credentials:ATS STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4088 CHAPMAN DR
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-6876
Mailing Address - Country:US
Mailing Address - Phone:330-472-6525
Mailing Address - Fax:
Practice Address - Street 1:4088 CHAPMAN DR
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-6876
Practice Address - Country:US
Practice Address - Phone:330-472-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer