Provider Demographics
NPI:1457909616
Name:BALANCIO, KATELYN (OD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:BALANCIO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6307
Mailing Address - Country:US
Mailing Address - Phone:209-477-4114
Mailing Address - Fax:209-477-9871
Practice Address - Street 1:4950 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6307
Practice Address - Country:US
Practice Address - Phone:209-477-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34375TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist