Provider Demographics
NPI:1548880446
Name:MIND BODY BALANCE CLINIC, PLLC
Entity type:Organization
Organization Name:MIND BODY BALANCE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:QUINTANA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-649-0629
Mailing Address - Street 1:284 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5538
Mailing Address - Country:US
Mailing Address - Phone:630-649-0629
Mailing Address - Fax:
Practice Address - Street 1:284 VISTA DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5538
Practice Address - Country:US
Practice Address - Phone:331-201-2863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty