Provider Demographics
NPI:1568903433
Name:BALLITCH, TIMOTHY (DC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BALLITCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8765 W KELTON LN STE B4
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5010
Mailing Address - Country:US
Mailing Address - Phone:623-299-7853
Mailing Address - Fax:
Practice Address - Street 1:8765 W KELTON LN STE B4
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5010
Practice Address - Country:US
Practice Address - Phone:623-299-7853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8620111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8620Medicaid