Provider Demographics
NPI:1629476726
Name:BALANCED LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:BALANCED LIFE CHIROPRACTIC
Other - Org Name:EVERGREEN WELLNESS STUDIOS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:I
Authorized Official - Credentials:DC
Authorized Official - Phone:208-293-7150
Mailing Address - Street 1:1640 W CHERRY LN
Mailing Address - Street 2:#130
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8187
Mailing Address - Country:US
Mailing Address - Phone:208-895-8595
Mailing Address - Fax:
Practice Address - Street 1:1640 W CHERRY LN
Practice Address - Street 2:#130
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8187
Practice Address - Country:US
Practice Address - Phone:208-895-8595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty