Provider Demographics
NPI:1700402930
Name:BALANCED LIFE CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:BALANCED LIFE CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:M
Authorized Official - Last Name:KONOSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-351-1273
Mailing Address - Street 1:123 VALLEY RD W
Mailing Address - Street 2:
Mailing Address - City:KUNKLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18058-7756
Mailing Address - Country:US
Mailing Address - Phone:570-351-1273
Mailing Address - Fax:
Practice Address - Street 1:2331 ROUTE 209 STE 4
Practice Address - Street 2:
Practice Address - City:SCIOTA
Practice Address - State:PA
Practice Address - Zip Code:18354-7770
Practice Address - Country:US
Practice Address - Phone:570-351-1273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty