Provider Demographics
NPI:1588842371
Name:BALA CHIROPRACTIC
Entity Type:Organization
Organization Name:BALA CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BALA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-624-3600
Mailing Address - Street 1:635 WEST HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1941
Mailing Address - Country:US
Mailing Address - Phone:618-624-3600
Mailing Address - Fax:618-628-1216
Practice Address - Street 1:635 WEST HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1941
Practice Address - Country:US
Practice Address - Phone:618-624-3600
Practice Address - Fax:618-628-1216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV02121Medicare UPIN
ILK11918Medicare PIN