Provider Demographics
NPI:1720852007
Name:GDA BLALANCE MEDICAL LLC
Entity type:Organization
Organization Name:GDA BLALANCE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTACHE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:239-692-2630
Mailing Address - Street 1:4349 18TH PL SW
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-5917
Mailing Address - Country:US
Mailing Address - Phone:239-692-2630
Mailing Address - Fax:
Practice Address - Street 1:4349 18TH PL SW
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-5917
Practice Address - Country:US
Practice Address - Phone:239-692-2630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty