Provider Demographics
NPI:1730299652
Name:BALANCED LIFE SC
Entity Type:Organization
Organization Name:BALANCED LIFE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KWAN BO
Authorized Official - Middle Name:
Authorized Official - Last Name:JIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-496-4216
Mailing Address - Street 1:PO BOX 946
Mailing Address - Street 2:
Mailing Address - City:STREAMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60107-3305
Mailing Address - Country:US
Mailing Address - Phone:630-497-1730
Mailing Address - Fax:630-497-1379
Practice Address - Street 1:1650 MOON LAKE BLVD
Practice Address - Street 2:ATTN: DR JIN
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60194-1010
Practice Address - Country:US
Practice Address - Phone:947-496-4216
Practice Address - Fax:847-358-7516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14712OtherPROVIDER MEDICARE NUMBER
ILK14710OtherPROVIDER MEDICARE NUMBER
ILK14711OtherPROVIDER MEDICARE NUMBER
ILK14710OtherPROVIDER MEDICARE NUMBER
ILK14711OtherPROVIDER MEDICARE NUMBER
IL210974Medicare ID - Type Unspecified
ILK14712OtherPROVIDER MEDICARE NUMBER