Provider Demographics
NPI:1881827947
Name:DYNAMIC BALANCE WELLNESS, L.L.C
Entity Type:Organization
Organization Name:DYNAMIC BALANCE WELLNESS, L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:860-749-4148
Mailing Address - Street 1:150 HAZARD AVE STE C7
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4587
Mailing Address - Country:US
Mailing Address - Phone:860-749-4148
Mailing Address - Fax:860-749-4241
Practice Address - Street 1:150 HAZARD AVE STE C7
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4587
Practice Address - Country:US
Practice Address - Phone:860-749-4148
Practice Address - Fax:860-749-4241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT01590111N00000X
CT000329171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty