Provider Demographics
NPI:1730335977
Name:THE ICON FOR BALANCED HEALTH, LLC
Entity type:Organization
Organization Name:THE ICON FOR BALANCED HEALTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-724-0190
Mailing Address - Street 1:250 BLOSSOM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4204
Mailing Address - Country:US
Mailing Address - Phone:281-724-0190
Mailing Address - Fax:281-724-0191
Practice Address - Street 1:250 BLOSSOM ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4204
Practice Address - Country:US
Practice Address - Phone:281-724-0190
Practice Address - Fax:281-724-0191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty