Provider Demographics
NPI:1487161766
Name:BALANCED ENERGY WELLNESS, LLC
Entity type:Organization
Organization Name:BALANCED ENERGY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LICENSED ACUPUNCTURIST
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:RAWLS
Authorized Official - Last Name:WHITTLESEY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:678-871-9642
Mailing Address - Street 1:457 CASTLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2012
Mailing Address - Country:US
Mailing Address - Phone:678-848-3319
Mailing Address - Fax:
Practice Address - Street 1:259 HIGHWAY 74 N STE 2
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3562
Practice Address - Country:US
Practice Address - Phone:678-871-9642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA353171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA353OtherGEORGIA ACUPUNCTURE LICENSE #
1063925832OtherNPI - TYPE 1