Provider Demographics
NPI:1639561806
Name:BALANCED LIFE PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:BALANCED LIFE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:E
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-686-6168
Mailing Address - Street 1:3240 MOUNT MORIAH AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7805
Mailing Address - Country:US
Mailing Address - Phone:270-686-6168
Mailing Address - Fax:270-686-6140
Practice Address - Street 1:3240 MOUNT MORIAH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7805
Practice Address - Country:US
Practice Address - Phone:270-686-6168
Practice Address - Fax:270-686-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty