Provider Demographics
NPI:1871832782
Name:VITAL BALANCE ACUPUNCTURE AND HERBAL MEDICINE LLC
Entity Type:Organization
Organization Name:VITAL BALANCE ACUPUNCTURE AND HERBAL MEDICINE LLC
Other - Org Name:DR. MARK VANOTTERLOO DAOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:VANOTTERLOO
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:720-295-9323
Mailing Address - Street 1:4288 YOUNGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2436
Mailing Address - Country:US
Mailing Address - Phone:720-295-9323
Mailing Address - Fax:720-295-9323
Practice Address - Street 1:4288 YOUNGFIELD ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2436
Practice Address - Country:US
Practice Address - Phone:720-295-9323
Practice Address - Fax:720-295-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1763171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1588937759OtherNPPES