Provider Demographics
NPI:1184734931
Name:BALANCE REHABILITATION, INC.
Entity type:Organization
Organization Name:BALANCE REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE/BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIVELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-465-9500
Mailing Address - Street 1:23832 ROCKFIELD BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2820
Mailing Address - Country:US
Mailing Address - Phone:949-465-9500
Mailing Address - Fax:949-465-9506
Practice Address - Street 1:23832 ROCKFIELD BLVD STE 160
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2820
Practice Address - Country:US
Practice Address - Phone:949-465-9500
Practice Address - Fax:949-465-9506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24624225100000X
CAPT29999225100000X
CAPT30004225100000X
CAOT142225X00000X
CAPT246062251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ08672ZOtherBLUE SHIELD OF CALIFORNIA
CAW17212Medicare ID - Type UnspecifiedMCR GROUP NUMBER