Provider Demographics
NPI:1831670603
Name:TERRANCE BALLARD MD PC, DBA WELLTRAC
Entity Type:Organization
Organization Name:TERRANCE BALLARD MD PC, DBA WELLTRAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:PAULINE
Authorized Official - Last Name:WAGHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-266-8180
Mailing Address - Street 1:2510 WIGWAM PKWY STE 109
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7115
Mailing Address - Country:US
Mailing Address - Phone:702-266-8180
Mailing Address - Fax:702-558-8275
Practice Address - Street 1:2510 WIGWAM PKWY STE 109
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7115
Practice Address - Country:US
Practice Address - Phone:702-266-8180
Practice Address - Fax:702-558-8275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7062261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service