Provider Demographics
NPI:1578585576
Name:ENRICO BALCOS MEDICAL INC
Entity Type:Organization
Organization Name:ENRICO BALCOS MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ENRICO
Authorized Official - Middle Name:U
Authorized Official - Last Name:BALCOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-518-5445
Mailing Address - Street 1:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91031-1526
Mailing Address - Country:US
Mailing Address - Phone:888-518-5445
Mailing Address - Fax:949-258-5551
Practice Address - Street 1:4619 ROSEMEAD BLVD
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-1478
Practice Address - Country:US
Practice Address - Phone:626-286-1191
Practice Address - Fax:949-258-5551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA633632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ56941YOtherBLUE SHIELD OF CALIFORNIA
CA247792OtherMHN
CA1902825128OtherNPI FOR CANYON RIDGE HOSP
CAA63363OtherCA LICENSED
CA00A633630Medicaid
CA1194758623OtherNPI FOR BHC HOSPITAL
CAH45300Medicare UPIN
CA00A633630Medicaid
CAZZZ56941YOtherBLUE SHIELD OF CALIFORNIA