Provider Demographics
NPI:1811296304
Name:WELLNESS & BALANCE CENTER
Entity type:Organization
Organization Name:WELLNESS & BALANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MADIC
Authorized Official - Suffix:
Authorized Official - Credentials:THERAPIST
Authorized Official - Phone:954-410-1607
Mailing Address - Street 1:3900 NW 79TH AVE
Mailing Address - Street 2:SUITE 324
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6556
Mailing Address - Country:US
Mailing Address - Phone:305-599-7709
Mailing Address - Fax:
Practice Address - Street 1:3900 NW 79TH AVE
Practice Address - Street 2:SUITE 324
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6556
Practice Address - Country:US
Practice Address - Phone:305-599-7709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0400X
FLMM26420225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty