Provider Demographics
NPI:1952847550
Name:BALBOA, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BALBOA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N SUNSET STRIP ST
Mailing Address - Street 2:
Mailing Address - City:KENEDY
Mailing Address - State:TX
Mailing Address - Zip Code:78119-2208
Mailing Address - Country:US
Mailing Address - Phone:830-583-9155
Mailing Address - Fax:830-583-9745
Practice Address - Street 1:107 N SUNSET STRIP ST
Practice Address - Street 2:
Practice Address - City:KENEDY
Practice Address - State:TX
Practice Address - Zip Code:78119-2208
Practice Address - Country:US
Practice Address - Phone:830-583-9155
Practice Address - Fax:830-583-9745
Is Sole Proprietor?:No
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist