Provider Demographics
NPI:1619722931
Name:BALANCED LIFE & WELLNESS PLLC
Entity Type:Organization
Organization Name:BALANCED LIFE & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DESARETA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:704-609-5288
Mailing Address - Street 1:PO BOX 38514
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-1009
Mailing Address - Country:US
Mailing Address - Phone:704-609-5288
Mailing Address - Fax:
Practice Address - Street 1:1550 UNION RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5522
Practice Address - Country:US
Practice Address - Phone:704-609-5288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty