Provider Demographics
NPI:1588977854
Name:ADVANCED BALANCE STUDIO
Entity type:Organization
Organization Name:ADVANCED BALANCE STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DONAYRE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:310-752-3769
Mailing Address - Street 1:1921 N GAFFEY ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-1264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1921 N GAFFEY ST
Practice Address - Street 2:SUITE I
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-1264
Practice Address - Country:US
Practice Address - Phone:310-833-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT284342251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT28434BMedicare PIN