Provider Demographics
NPI:1629478037
Name:A BALANCED LIFE WELLNESS CLINIC AND APOTHECARY, LLC
Entity Type:Organization
Organization Name:A BALANCED LIFE WELLNESS CLINIC AND APOTHECARY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTILO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-602-1518
Mailing Address - Street 1:1818 LIBRARY ST
Mailing Address - Street 2:STE 500
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-6242
Mailing Address - Country:US
Mailing Address - Phone:301-602-1518
Mailing Address - Fax:
Practice Address - Street 1:1818 LIBRARY ST
Practice Address - Street 2:STE 500
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-6242
Practice Address - Country:US
Practice Address - Phone:301-602-1518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty