Provider Demographics
NPI:1780710194
Name:TRI CITY BALANCE CENTER S.C.
Entity type:Organization
Organization Name:TRI CITY BALANCE CENTER S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:BUKOWY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-377-4020
Mailing Address - Street 1:302 RANDALL RD # 104-A
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4209
Mailing Address - Country:US
Mailing Address - Phone:630-377-4020
Mailing Address - Fax:630-377-4023
Practice Address - Street 1:302 RANDALL RD # 104-A
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4209
Practice Address - Country:US
Practice Address - Phone:630-377-4020
Practice Address - Fax:630-377-4023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36052366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532303OtherBCBS
ID=========OtherPHCS
IL04532303OtherBCBS
IL04532303OtherBCBS
ILK22509Medicare ID - Type Unspecified