Provider Demographics
NPI:1053564666
Name:BALLAURA INCORPORATED
Entity type:Organization
Organization Name:BALLAURA INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-539-7726
Mailing Address - Street 1:PO BOX 8022
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-8022
Mailing Address - Country:US
Mailing Address - Phone:360-539-7726
Mailing Address - Fax:360-539-7729
Practice Address - Street 1:2413 PACIFIC AVE SE
Practice Address - Street 2:SUITE D
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2087
Practice Address - Country:US
Practice Address - Phone:360-539-7726
Practice Address - Fax:360-539-7729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty