Provider Demographics
NPI:1811191364
Name:BALK, PETER (LAC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BALK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1609
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-0109
Mailing Address - Country:US
Mailing Address - Phone:360-385-4383
Mailing Address - Fax:360-344-3702
Practice Address - Street 1:618 WILLOW ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6422
Practice Address - Country:US
Practice Address - Phone:360-385-4383
Practice Address - Fax:360-344-3702
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00000533171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist