Provider Demographics
NPI:1427159805
Name:BALANCE CHIROPRACTIC CENTER, LLC
Entity type:Organization
Organization Name:BALANCE CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOJALLU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-240-0136
Mailing Address - Street 1:10033 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5799
Mailing Address - Country:US
Mailing Address - Phone:262-240-0136
Mailing Address - Fax:262-240-0139
Practice Address - Street 1:10033 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5799
Practice Address - Country:US
Practice Address - Phone:262-240-0136
Practice Address - Fax:262-240-0139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3228111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38893100Medicaid
WIU57093Medicare UPIN